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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2001  |  Volume : 12  |  Issue : 3  |  Page : 398-405
Design of Water Treatment Plants in the Year 2000 and Beyond

Division of Nephrology, Dialysis and Transplantation, University Hospital of Modena, Italy

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Keywords: Hemodialysis, Water treatment, Contaminants, Water standards.

How to cite this article:
Cappelli G, Perrone S, Inguaggiato P, Ferramosca E, Albertazzi A. Design of Water Treatment Plants in the Year 2000 and Beyond. Saudi J Kidney Dis Transpl 2001;12:398-405

How to cite this URL:
Cappelli G, Perrone S, Inguaggiato P, Ferramosca E, Albertazzi A. Design of Water Treatment Plants in the Year 2000 and Beyond. Saudi J Kidney Dis Transpl [serial online] 2001 [cited 2022 Jan 18];12:398-405. Available from: https://www.sjkdt.org/text.asp?2001/12/3/398/33564

   Introduction Top

During the last decade, a consensus has been reached among nephrologists on water quality being an essential key factor in modern dialysis. Since 1982, the Association for Advancement of Medical Instrumentation (AAMI) has set standards to avoid clinical problems of tap water from municipal supplies but most of the interest was focused on chemical contamination. [1],[2] Studies on bio­compatibility during the 80s drew more attention to the microbial contaminants. [3],[4] At present, there is evidence on the pyrogenic substances of bacterial origin derived from the contaminated dialysate, which penetrate the intact dialyzer membranes and induce an inflammatory response in the patients. This reaction leads to the development or worsening of chronic complications such as bone disease, anemia, encephalopathy and amyloidosis. [5],[6] Therefore, water treatment represents a fundamental aspect of the modern hemodialysis and technical aspects are of vital importance.

   The Standard Setting Top

A proper water quality is usually defined as the one fulfilling the most up-to-date standards. This is a basic requirement as standards are derived from the official health care institutions and usually entered in national legislation. On the other hand, national standards may differ in the number and accepted levels of contaminants from one set of standards to another, with the risk of potentially toxic compounds not being included. This is due partly to the different basal levels of contaminants in tap water in different countries and partly to the slow procedure in setting or modifying a standard level. [Table - 1] shows the recom­mended limit values for USA (AAMI­RD5) [1] and Europe (European Pharma­copoeia 3 rd Edition) and Renal Association in UK [7],[8] as well as variations proposed for the United States by AAMI with new standards to be released in the next few months (AAMI-RD62). Anyway, it remains difficult to achieve a perfect chemical purity as new pollutants are released every year to the air by industry or dispersed by agriculture to the groundwater. Toxico­logical knowledge is linked to the develop­ment in analytical methods as well as to the effects of a toxic exposure to a specific clinical picture. Therefore, the definition of an acceptable level of contamination could be sometimes inadequate or impossible to define. For example the accepted level of certain pesticides, fertilizers, aromatic hydrocarbons, several trace elements or radionuclides in dialysis fluids are awaited even though some limits have been determined for the drinking water. Moreover, responsibility in complying with standards has been defined in some countries. The AAMI, for example, states that it is the physician in charge of the unit that has the ultimate responsibility for selecting the maximum allowable levels of contaminants and for monitoring the treated water. On the other hand, the topic is not so clearly defined in Europe. [1]

   Water treatment modalities Top

Due to the great variation in feed water quality, the requirements of water puri­fication in individual dialysis clinics may vary. The system has to be customized for each single center, depending on the feeding water quality and the required capacity. There are several possibilities, but it is the responsibility of the manufacturers or suppliers of the purification system to recommend the components that are able to meet the requirements. The water purify­cation system for hemodialysis in the United States needs to comply with the Food and Drug Administration (FDA) regulation of class II devices; while in Europe, it should comply with the rules for medical devices in risk class IIb.

The most frequently used components are represented by mechanical filters, oxidizing filters, cartridge filters, ultrafilters, carbon filters, ion exchanger and reverse osmosis units. [9] To ensure removal of all possible contaminants (particulate matter, soluble and insoluble inorganic compounds, soluble organic substances, heavy metals, trace elements, bacteria and pyrogens) the system is composed of several serially oriented components usually divided into a pre­treatment section and a final production unit. [Table - 2] shows the efficiency of different methods in removing the most common chemical contaminants. Mechanical filters are used to remove large particles and turbidity from the incoming water, and therefore they protect the following components from clogging or being damaged by particulate matter. Oxidizing filters remove excessive iron, manganese and sulfides by oxidizing and adsorbing these ions. Cartridge filters are used to protect components from small particles and they usually work in the range from 50 up to 5 or 3 microns. Ultrafiltration cartridges remove bacteria, pyrogens and other macromolecular compounds, by a combined mechanism of filtration and absorption. They are used to obtain ultrapure water or to avoid back contamination from distribution loop to the final osmosis unit. Ultrafilters reject contaminants in the range of 1000 Dalton to 0.1 µm particles, allowing most ions and small organics, such as glucose, to permeate the porous structure. Carbon filters absorb low molecular weight organic compounds such as chlorine, chloramines and some pyrogens from the water. The most common ion-exchangers used in dialysis are water softeners; they exchange calcium and magnesium present in the water with sodium salts, thus changing hard water to soft water with a proportional increase in sodium ions. Similarly ion exchange deionizers use two types of synthetic resins: one to remove the positively charged ions (cations) and another to remove the negatively charged ions (anions). Resins have limited capacities and need to be regenerated upon exhaustion. A deminera­lization or deionization unit is typically used on water that has already been prefiltered and uses a two-stage process to remove virtually all ionic material remaining in water. Deionizers have usually two-bed or mixed-bed configuration in which the cationic and anionic resins are in separate or single tank, respectively. Recently an electrical current has been used to reduce the ionic content of water, using special semipermeable membranes based on the charges of the ions. This component is called electrodialysis, which improves the efficiency of the classic deionizers, avoiding the troubles of using chemicals for regeneration. Two flat sheet membranes, to preferentially permeate cations and anions, respectively, are stacked alternatively with flow channels between them. Cathode and anode electrodes are placed on each side of the alternating stack of membranes to draw most ions through the membranes. This leaves much lower concentrations of the ions in water in the alternate channels. A recent development has improved the efficiency of electrodialysis by reducing scaling and fouling problems on membranes.

This has been obtained by reversing the polarity of the electrodes periodically and is called electrodialysis reversal.

Reverse osmosis removes virtually all organic compounds; 90 to 99% of all ions, and 99.9% of viruses, bacteria and pyrogens. Reverse osmosis membranes represent the heart of any water treatment system. They may sometimes differ in the efficiency of rejection or resistance to disinfectants. The membranes are sensitive and can be easily damaged by excessive hardness, iron and chlorine in the feeding water; hence a correct pretreatment is essential for the membranes to function properly.

   The design of the water treatment plant Top

The key elements to be considered for choosing the most appropriate components to include in the water system are the feed water contamination levels and the maximum allowed or wished-for levels of contaminants in the final product water. One has also to take into account the amount of water required and the flow rate for each device. Based on removal ratio, that is the ratio for each known contaminant of feed water value to the standard level, it is possible to select the most appropriate component. [Table - 3] illustrates the possible selections based on removal ratio. [Figure - 1] shows a flow diagram of a typical water treatment system used in the production of highly purified water. Starting from the tap water a pressure reducer is sometimes needed to enter water into the pre-treatment section [Figure - 1]: shows the components from 1 to 13, which include a 25 µm cartridge filter (1), dual water softener (3,5) with brine tanks (2,4), two carbon adsorption filter in series (6,7) and a final 5 µm cartridge filter (8). The components 9 and 10 are a double reverse osmosis in series, where rejected water from the second osmosis is not discharged but is sent back to the pre-treatment section to spare it. The final component is a loop distribution system, where sampling points (12) are included between the 0.2 µm-antibacterial microfilters (11,13) to avoid back­contamination of the loop or of the osmosis membrane. This is a general description of the commonly used water treatment plant. Different plants, however, can achieve, in special situations, better results. [10],[11] In general a pre-treatment with filters, softeners and activated carbons is always necessary. Placement of the activated carbon as the last component ensures a higher level of chlorine to disinfect softeners. However, the carbon resins will last less, and therefore it represents a solution with a higher maintenance cost. For the final treatment section, the combination of a single reverse osmosis with ultrafiltration or a deionizer unit has been reported. The first combination is especially active on bacterial contamination, while the second one on chemical contaminants. [12] The combination of the two reverse osmosis units in series is preferable [13],[14] since in case of breakdown of any single osmosis component, the remaining unit can still serve to get reasonably good water quality while awaiting repair.

How to avoid bacterial contamination

Several studies have demonstrated that many dialysis complications are caused not only by bacteria or endotoxins but also by small derived fractions of bacterial origin able to induce cytokines production. [15] Current water treatment plants are effective chemical purifiers but many of them are, at the same time, good breeding grounds for bacteria. Reverse osmosis membranes offer 99.9% rejection of bacterial pyrogens, which could be inadequate in the presence of high contamination in the pretreatment section. Resin beds, multimedia filters, porous surfaces of some plastic and metal piping and areas of stagnant or laminar water flow (Reynolds number < 2000) are excellent in promoting bacterial growth. [3] Moreover, reverse osmosis membranes could be made of different synthetic polymers with variable performances in rejection rate for ionic species, temperature limit of stability, oxidation resistance (chemical resistance to the oxidizing agents such as chlorine), and, most importantly, biological resistance (the ability to withstand bacterial attack). If bacterial colonisation occur, the performance of even the best reverse osmosis membrane (modified polyamide, thin film composite) may decrease. Therefore, a new concept of hygienic chain has emerged. According to this concept, every section of the water treatment system has to have as low contamination as possible. To achieve this goal, the design of the water treatment system and its materials represent key points. Storage tanks should be avoided, due to difficulties in disinfection, as well as dead legs. Unprotected sampling or drain ports should be abandoned, and adequate drainage should be assured to the pipe. A constantly moving water is considered an essential factor to avoid bacterial growth; therefore a close loop distribution system represents the optimum design. Material used for piping has to offer smooth surfaces and good resistance to the disinfection procedure and to the release of chemicals or particles. [16] Medical grade polyvinyl chloride (PVC) has been the most used piping material. However, the AISI 316L stainless steel, cross-linked polyethylene (PEX) or polyvinylidene fluoride (PVDF) offer more advantages and are increasingly used. Notwithstanding the best water system, bacterial contamination will appear and therefore it is imperative to adopt some disinfection protocols to hold contamination at acceptable levels. Most disinfectants are chemicals (chlorine, chlorine dioxide, formaldehyde, glutaraldehyde, ozone, peracetic acid), [17] but experiences have also been reported with hot water (70°C or more), vapor or ultraviolet irradiation. The efficacy of this last process has been questioned as in killing bacteria it delivers bacterial fragments into the fluids. The ideal disinfectant should kill all strains of bacteria and inactivate the bacterial fractions, it should be easily removed from the system and monitored and it should also have no deleterious effect on the piping material or osmosis membrane. Recently, biofilm formation has been incriminated in the resistance to disinfectants and as a consequence the selection of the chemical and/or process used in disinfection procedure must be based on careful evaluation and testing of this aspect too. [18] As biofilms are very difficult to destroy, their formation should be prevented, using not only adequate material and a design avoiding low shear rates associated with slow water flow, but also using a disinfectant with detergent activity on a regular basis. [19],[20] .

Water quality controls and assurance

Whatever the water system in use, the only way to assure proper quality of water is to have a maintenance and quality control program. [21] Some parameters may be checked continuously with an automatic device while for most of them there should be periodical monitoring of which the frequency is regulated on manufacturer recommendations and on suggestions from the same reference standards authorities, even though, the monitoring process has not been clearly defined for each contaminant yet. [1],[7] Recently a governmental document in France has laid technical details for "on-line" treatments and could re~resent a model for standard hemodialysis. [14] It suggests that, following validation, conductivity should be measured daily, chemical contaminants included in the standards of the European Pharmacopoeia should be checked at least every three months, while bacteria and endotoxins have to be checked monthly. Moreover, it recom­mends performing microbiological controls after maintenance check-ups. Guidelines of the Renal Association in UK suggested some years ago monitoring tap water monthly for total chlorine and nitrates and every three months for all chemicals. Furthermore, they suggested checking the bacteria and endotoxins in the finally produced water from the plant weekly, total chlorine and nitrates monthly, and all chemical contaminants in the tap water every three months. [8] The control program in a specific dialysis unit should be based not only on these suggestions but also on the knowledge of the specific local contaminants that require more frequent intervals, and on the balance with costs. [21]

Final remarks

In search of adequate dialysis, [22] many clinical and technical improvements have been achieved in the last decade, from exact dose quantification to better toxins removal as well as to an increased biocompatibility of the whole dialytic system. In this regard the use of ultrapure dialysis fluid represents an increasing tendency. [23] This high level quality water should not only be reserved to high-flux or on-line treatments but should be adopted in all treatments due to the awareness of the extent of microbiological contamination. With the exception of some centers, recent reports show that there is still a high percentage of centers that do not comply with the set-up standards either microbiologically (from 8% to 49%) or chemically (14%), in the United States, [24] Canada [12] or Europe. [25],[26],[27],[28] Furthermore, there is still a controversy on the methods of microbiological analysis. Bacterial counts increase on all types of media if incubation time is prolonged from the standard 48 hours to seven days, while low nutrient media gives better results. [29] The presence of a quality assurance program is the cornerstone for obtaining high quality water. It is hoped that in the future, ultrapure water philosophy will spread among nephrologists to improve the quality of dialysis. Whatever the modality of treatment in use, quality controls should include the whole production chain. [3],[14] As with any other quality system it will only work if the standards laid down are adhered to, and the methods of analysis are correctly implemented.

   References Top

1.American National Standards for Hemo­dialysis Systems. In AAMI: Standards and Recommended Practices, AAMI Ed. Arlington 1990;3:35-54.  Back to cited text no. 1    
2.Bommer J, Ritz E. Water quality-a neglected problem in hemodialysis. Nephron 1987;46:1-6.  Back to cited text no. 2    
3.Mion C, Canaud B, Garred LJ, Stec F, Nguyen QV. Sterile and pyrogen free bicarbonate dialysate: A necessity for hemodialysis today. In: Grunfeld JP, Bach JF, Funck-Brentano JL, Maxwell MH (Eds) Advances in Nephrology, Chicago: Mosby year Book, 1990;19:275-314.  Back to cited text no. 3    
4.Cappelli G. Dialysate contribution to bio­incompatibility in hemodialysis. Contemp Dial Nephrol 1991;12:20-22.  Back to cited text no. 4    
5.Baz M, Durand C, Ragon A, et al. Using ultrapure water in hemodialysis delays carpal tunnel syndrome. Int J Artif Organs 1991; 14:681-5.  Back to cited text no. 5  [PUBMED]  
6.Brunet P, Berland Y. Water quality and complications of hemodialysis. Nephrol Dial Transplant 2000;15:578-80.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.European Pharmacopoeia 3 rd Ed. Hemodialysis solutions, concentrated, water for diluting. Monograph 1997:1167. Council of Europe, Strasbourg 1996, pp 923.  Back to cited text no. 7    
8.The Renal Association. Treatment of adult patients with renal failure: Recommended standards and audit measures. Royal College of Physicians of London. London 1997 (2nd edition).  Back to cited text no. 8    
9.Henderyckx Y, Borremans M. Water quality testing and selection of equipment. In Lopot F (Ed): Water for hemodialysis. EDTNA-ERA series, 3. Ruddervoorde 1988, pp 69-104.  Back to cited text no. 9    
10.Cartwright PS. Hemodialysis water treatment systems design. Contemp Dial Nephrol 1995; 12:22-34.  Back to cited text no. 10    
11.Haynes J. Upgrade and planning of water purification systems. Dial Transplant 1995;24: 286-333.  Back to cited text no. 11    
12.Laurence RA, Lapierre ST. Quality of hemo­dialysis water: a 7-year multicenter study. Am J Kidney Dis 1995;25:738-50.  Back to cited text no. 12  [PUBMED]  
13.Polaschegg HD. Potential hazards of deionization systems used for water purification in hemodialysis. Artif Organs 1997;21:86.  Back to cited text no. 13  [PUBMED]  
14.Ministere de l'Emploi et de la Solidariete: Circulaire relative aux specifications techniques et a la securite de la pratique de l'hemofiltration et de l'hemodiafiltration en ligne dans etablissement de sante. Republique Francaise, Circulaire-DGS/DH/AFSSAPS n° 311; 7 Juin 2000.  Back to cited text no. 14    
15.Lonnemann G, Krautzig S, Kock KM. Quality of water and dialysate in hemodialysis. Nephrol Dial Transplant 1996;11:946-9.  Back to cited text no. 15    
16.Cappelli G, Ballestri M, Facchini F, Carletti P, Lusvarghi E. Leaching and corrosion of polyvinyl chloride (PVC) tubes in a dialysis water distribution system. Int J Artif Organs 1995;18:261-3.  Back to cited text no. 16  [PUBMED]  
17.Jensen E. Ozone: the alternative for clean dialysis water. Dial Transplant 1998;27:706-12.  Back to cited text no. 17    
18.Cappelli G, Ballestri M, Perrone S, Ciuffreda A, Inguaggiato P, Albertazzi A. Biofilms invade nephrology: effects in hemodialysis. Blood Purif 2000;18:224-30.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]
19.Vincent FC, Tibi AR, Darbord JC. A bacterial biofilm in a hemodialysis system, assessment of disinfection and crossing of endotoxin. ASAIO Trans 1989;35:310-3.  Back to cited text no. 19  [PUBMED]  
20.Man NK, Degremont A, Darbord JC, Collet M, Vaillant P. Evidence of bacterial biofilm in tubing from hydraulic pathway of hemo­dialysis system. Artif Organs 1998;22:596-600.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]
21.Cappelli G, Perrone S, Ciuffreda A. Water quality for on-line hemodiafiltration. Nephrol Dial Transpl 1998;13(Suppl 5):12-6.  Back to cited text no. 21    
22.Bosch JP. Beyond "adequate dialysis". Am J Kidney Dis 2000;35:xlvi-xlviii.  Back to cited text no. 22  [PUBMED]  
23.Ledebo I, Nystrand R. Defining the micro­biological quality of dialysis fluid. Artif Organs 1999;23:37-43.  Back to cited text no. 23  [PUBMED]  [FULLTEXT]
24.Klein E, Pass T, Harding GB, Wright R, Million C. Microbial and endotoxin contami­nation in water and dialysate in the central United States. Artif Organs 1990;14:85-94.  Back to cited text no. 24  [PUBMED]  
25.Kulander L, Nisbeth U, Danielsson BG, Eriksson O. Occurrence of endotoxin in dialysis fluid from 39 dialysis units. J Hosp Infect 1993;24:29-37.  Back to cited text no. 25  [PUBMED]  [FULLTEXT]
26.Bambauer R, Schauer M, Jung WK, Daum V, Vienken J. Contamination of dialysis water and dialysate. A survey of 30 centers. ASAIO J 1994;40:1012-6.  Back to cited text no. 26    
27.Arvanitidou M, Spaia S, Katsinas C, et al. Microbiological quality of water and dialysate in all haemodialysis centres of Greece. Nephrol Dial Transplant 1998;13: 949-54.  Back to cited text no. 27  [PUBMED]  [FULLTEXT]
28.Arvanitidou M, Spaia S, Askepidis N, et al. Endotoxin concentration in treated water of all hemodialysis units in Greece and inquisition of influencing factors. J Nephrol 1999;12:32-7.  Back to cited text no. 28  [PUBMED]  [FULLTEXT]
29.Pass T, Wright R, Sharp B, Harding GB. Culture of dialysis fluids on nutrient-rich media for short periods at elevated temperatures underestimate microbial contamination. Blood Purif 1996;14:136-45.  Back to cited text no. 29  [PUBMED]  

Correspondence Address:
G Cappelli
Division of Nephrology, University Hospital of Modena, Via Del Pozzo, 71, 41100 Modena
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