������������������ The function of kidney is to remove excess salts & waste products from the human body. Nonfunctional kidneys leads to problem in maintaining the level of sodium, potassium, and minerals and which results in congenital kidney disease. There are two types of dialysis treatment available: 1. Hemodialysis 2. Peritoneal dialysis. The working principle of these two methods varies slightly, but both operate Importance of Water Quality in Dialysis and on the same principles of replacing kidney function by eliminating the toxic products from the blood. need for Endotoxin Testing The dialysis fluid consists of up to 99% of reverse osmosis water; in addition, chemicals are added, such as acids, salts and bicarbonate. Dibyendu Maji & Soma Chatterjee / Lonza / February, 2011 slide 2 Indian Scenario : End Stage Kidney Disease Dialysis Types Hemodialysis Treatment: � 150,000 new patients develop end stage kidney failure each year in • Artificial kidney (hemodialyzer) used to remove the excretory products and fluids from India blood. � Only 3 percent patients receive kidney transplant • Dialysis patient undergoes small surgery that creates an access point in an arm or leg, and then the blood is allowed to flow through a hemodialyzer. � About 15-20 percent treated with dialysis • Hemodialysis treatment occurs 3 times a week , each session of 4 hr duration. Each � 820 plus Nephrologists exposure of 150 litres, one year exposure of 23400 litres of dialysis fluid . � 710 dialysis centers • Actual frequency and time of Hemodialysis treatment depends upon the condition of kidney, function, accumulation of toxic products in the blood etc. � 3000 dialysis machines Peritoneal Dialysis treatment: SK Agarwal, Chronic Kidney Disease in India: Challenges and Solutions ... Nephron Clin Pract • Dialysis is done without removing the blood from the body. 2009; • Catheter is placed in the abdomen by a minor surgery and catheter point is closed with a solution called the dialysate, which then fills the inner side of the abdomen. •Toxic substances in the blood filter through the blood vessels namely arteries and veins into the dialysate by osmotic process. slide 3 slide 4 Bacterial Growth in Dialysis Systems What is Endotoxin? � Water treatment must eliminate � Chemical Toxins � Bacterial Contaminants � Reverse Osmosis reduces bacteria and endotoxin levels � But, bacteria escape to downstream sites and begin to proliferate � If sanitation is inadequate, bacteria and endotoxin will reach dangerous levels Endotoxin is the natural form of lipopolysaccharide occurring in the outer layer of the bi-layered gram negative bacterial cell wall. The term lipopolysaccharide refers to the pure chemical form slide 5 slide 6 1
Why Monitor Endotoxin in HD ? Why Monitor Endotoxin in HD ? � Patients receiving hemodialysis therapy are exposed to approx. 400 L of water per week which is 20-25 fold greater than drinking water. This � The use of popular HD modalities, e.g. use of bicarbonates dialysates potentially exposes them to large amounts of endotoxin. and high flux dialysers are predisposed to bacterial contamination of the dialysate fluid increasing the endotoxin burden of these fluids. � Endotoxin in the Dialysis Fluids may enter the blood compartment and activate monocytes to produce pro-inflammatory cytokines. � Additionally, washing with water for the reuse of hemodialysers and centralized dialysate production also increases the risk of endotoxin � Evidence also shows Transmembrane Stimulation of Mononuclear Cells contamination. This practice is not being used anymore in the USA, Europe, Japan, but might be used elsewhere. � Increase in cytokines, mainly IL-1, IL-6 and TNF-alpha, is thought to be related to several distinct acute and chronic problems of HD patients. � In Hemodialysis systems, bacteria escape water treatment & reach downstream sites and begin to proliferate. In case of inadequate � Cytokines trigger a series of acute phase reactants and consequently, sanitation, bacteria and endotoxin will reach dangerous levels these patients exhibit a state of chronic microinflammation. � Studies indicate a relationship between chronic microinflammation and heart disease and mortality slide 7 slide 8 Why test for Endotoxin? Endotoxin in Dialysate � Dialysis was once only administered to patients with acute renal failure Endotoxin and was only administered over a very short period. � Now, chronic hemodialysis treatment can continue for years. Activation � Exposure to endotoxin can result in pyrogenic reactions: Chills, fever, BP of � Fever, chills, fall in blood pressure, Complement System � Activation of the complement system, � Release of cytokines, Release of Cytokines � Inflammation, � Resistance to recombinant human erythropoietin. Inflammation Resistance to rHuEPO slide 9 slide 10 Recombinant Human Erythropoietin RD52: Microbiological (rHuEPO) Cultures and Endotoxin Levels � Anemia is common in patients with renal failure. � rHuEPO is used to treat anemia in dialysis patients. Matthew J. Arduino, Dr.P.H. � Inflammation induced by exposure to endotoxin reduces the Chief, Environmental and Applied Microbiology Section effectiveness of rHuEPO resulting in higher doses. Division of Healthcare Quality Promotion National Center for Infectious Diseases � Studies show that reduction in endotoxin increases the effectiveness of Marduino@cdc.gov rHuEPO. http://www.cdc.gov/ncidod/hip/default.htm � Low endotoxin results in lower doses of rHuEPO. � Reduction of rHuEPO dose is a significant reason for AAMI lowering the Slides Used With Permission allowable endotoxin in water and dialysate. slide 11 2
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