Dialysis water

Most patients should eat a diet with no added salt because of associated hypertension or edema. In dialysis patients, sodium intake should be reduced in patients who gain excessive weight between dialysis. Potassium restriction is not usually necessary until oliguria supervenes. Dialysis patients, however, should be educated to what foods are high in potassium, such as citrus foods, nuts, bananas, in order to avoid very high serum levels of potassium before each dialysis. Water restriction may be necessary if predialysis hyponatremia becomes prominent. 

Table 6. Dialysis water contaminations in dialysis centers. Comparison of serum symptoms3 and patients with classicalb and acutec aluminum encephalopathy... 

Davidson et al. found that the cumulative risk of death due to dialysis dementia in patients whose water supply had a mean Al concentration >200 pg/L was significantly greater (27.9% deaths in the first 40 months) than the risk in patients whose mean water Al content was <200 pg/L (2.1% deaths in the first 490 months). The relation between the mean Al concentration in the dialysate and time to death was given in the formula [24] The time in months from the first symptoms of dialysis dementia to death = 65—0.081 x [mean Al concentration (pg/L) in dialysis water]. 

R. W. Farmer and S. L. Kovacic, Catalytic activated carbon offers breakthrough for dialysis water treatment. Dialysis Transplantation, November 26, 771-775 (1997). 

Consumption of drinking water is the most probable route of exposure to chlorine dioxide and its by-products. Patients undergoing hemodialysis may be directly exposed to chlorine dioxide through dialysis water disinfected with chlorine dioxide. Chlorine dioxide is a gas therefore, inhalation is also an exposure pathway. 

A1 intake include switching from Al-contairdng phosphate binders to calcium-containing phosphate binders, ensuring that dialysis water contains less than lOfXg/L of Al, and ensuring that the albumin used during postdialysis therapy is Al-free. 

Copper used in the wiring of dialysis systems may be leached in an acidic medium. It then diffuses into the blood, causing hemolysis. Symptoms consist of flushing, chills, nausea, vomiting, abdominal cramps, and diarrhea. This problem can be avoided by deionization of the dialysis water. The deionizer should be checked periodically to assure it is not being exhausted (M23). 

Zinc may also be leached from new galvanized iron piping. The plasma and red blood cells take up zinc even when its concentration in the dialysate is only one-third that of the plasma, and this may cause a severe hemolytic anemia. Deionization of the dialysis water should prevent this problem (P10). 

The use of reverse osmosis to treat dialysis water does not remove chloramine, but the addition of ascorbic acid does. Treating the dialysis water with activated charcoal effectively removes chloramine, but periodic water testing with o-tol-idine should nevertheless be undertaken. This reagent detects total chloride, i.e., OC1, HOC1, NHC12, and NC13. Interestingly, chloramine contamination of natural waters has also caused hemolysis in several species of freshwater fish (El). 

Health Region of Sivas, Turkey. Other factors in this study included a probable deficiency in vitamin D, because of the lack of sunshine, and a deficiency in calcium in the diet after weaning. The potential skeletal toxicity of excess strontium in humans is supported by several reports indicating that hemodialysis patients have impaired handling of strontium and that strontium in dialysis water is a significant contributor to dialysis-associated osteomalacia. 

Initiator (and amount) mol/dm X 10 Surfactant Amount mol/dm X10 Pzn Temp. °C Partide size nm Tg after dialysis water water + °C Ethanol °C ... 

Water samples from various sources can also be analyzed (Parkinson et al., 1982) such as tap-water from patients on home dialysis. Water used to prepare dialysate solutions should be checked as a possible source for introducing aluminium into the dialysis system. Aluminium-free water for the preparation of standards, solutions and dilutions for analysis can be achieved by distilling, deionizing, passing through reverse osmosis, or a combination of the three. Analysis of this type of water should result in no detectable levels of aluminium (Smeyers-Verbeke et al., 1980). 

DETERMINATION OF CHLORINATED COMPOUNDS IN DIALYSIS WATER AND IN BIOLOGICAL FLUIDS/MATRICES... 

In this protocol, headspace-solid-phase microextraction (HS-SPME) coupled with gas chromatography/mass spectrometry (GC/MS) has been applied to detect chlorinated compounds, namely dichloromethane (DCM), trichloroethylene (TCE), and tetrachloroethylene (or perchloroethylene [PCE]) in dialysis water and biological fluids such as blood and urine. 

Although this method has been developed to detect DCM, TCE, and PCE in dialysis water, urine, and blood, the same approach could easily be extended to the analysis of other biological fluids. 

The matrices involved in this procedure are distillate water, dialysis water, urine, and blood. 

Generally, in distilled water, chlorinated compounds are undetectable, while they could be measured in dialysis water, blood, and urine, even in the case of unexposed subjects, due to the fact that DCM,TCE, and PCE are ubiquitous pollutants. However, in literature, it has been reported that in many biological samples, even from unexposed subjects, chlorinated compounds are detectable [3]. 

Therefore, it is crucial to check the blank of the samples (dialysis water and the pool of blood and urine) used to assess quality control procedure and method validation. 

This demonstration procedure should be performed on distilled water (where no interferences should be present) and then on matrix samples (dialysis water, urine, and/or blood) to evaluate the weight of matrix effect on the reliability of the method. 

This procedure entails analysis of distilled water, blanks (no contaminated dialysis water, and/or blood and/or urine from unexposed subjects), and fortified blanks. ... 

Prepare four replicate fortified blanks consisting of noncontaminated dialysis water, urine, and/or blood spiked at 50 and 500 pg/L with the target compounds using a concentrated stock solution. The methanolic standard stock solution can be prepared in the laboratory from pure compounds as described in Section 29.2.1. Analyze the fortified blanks according to the procedure described in this unit. The mean value should be within a range of 70%-130% of the true value, and %RSD (relative standard deviation) should be <20%. 

One field blank (noncontaminated dialysis water, and urine and blood from nonexposed subjects) should be determined every 10 samples to confirm that all interferences introduced by the equipment and chemicals are under control. In fact, no differences should be observed between this field blank and those produced during the demonstration of the field method if not, check for possible contamination. 

In order to avoid loss of analytes during collection and storage, 2 mL of the sample (dialysis water, and/or urine and/or heparinized blood) should be immediately transferred to 4.0-mL SPME glass vials containing 1.0 g of NaCl. 

To evaluate occupational exposure or (dialysis) water contamination by DCM, TCE, and PCE, the calibration model should be set according to the entity of the exposure. 

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