• Water quality for haemodialysis. Nephrology 2005 Oct;10(S4):S75-7.



• Water quality for haemodialysis. Westmead NSW (Australia): CARI - Caring for Australasians with Renal Impairment; 2005 Jul. 7 p. [19 references]

This is the current release of the guideline.

End-stage kidney disease (ESKD)

Evaluation
Management
Treatment

Family Practice
Nephrology
Nursing

Allied Health Personnel
Clinical Laboratory Personnel
Nurses
Physicians

To review the available evidence for the benefit of regular testing and audit of water treatment systems and quality of water produced for hemodialysis

Patients with end-stage kidney disease (ESKD) on prolonged hemodialysis

Evaluation

1. Chemical testing for contamination of dialysate
2. Microbial testing for contamination of dialysate

Management/Treatment

1. Optimal dialysate production for hemodialysis
2. Use of ultrapure water for hemodialysis

• Chemical contamination of dialysate
• Microbial contamination of dialysate
• Mortality

Searches of Electronic Databases

Databases searched: Medical Subject Headings (MeSH) terms and text words for dialysis were combined with MeSH terms and text words for water purification, chlorine, fluorides, water, water microbiology, water supply and water pollution, and then combined with the Cochrane highly sensitive search strategy for randomised controlled trials. The search was carried out in Medline (1966 – July Week 2 2004). The Cochrane Renal Group Trials Register was also searched for trials not indexed in Medline.

Date of searches: 27 July 2004.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Levels of Evidence

Level I: Evidence obtained from a systematic review of all relevant randomized controlled trials (RCTs)

Level II: Evidence obtained from at least one properly designed RCT

Level III: Evidence obtained from well-designed pseudo-randomized controlled trials (alternate allocation or some other method); comparative studies with concurrent controls and allocation not randomized, cohort studies, case-control studies, interrupted time series with a control group; comparative studies with historical control, two or more single arm studies, interrupted time series without a parallel control group

Level IV: Evidence obtained from case series, either post-test or pretest/post-test

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Not stated

Expert Consensus

Not stated

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Comparison with Guidelines from Other Groups
Peer Review

Recommendations of Others. Recommendations regarding water quality for hemodialysis from the following groups were discussed: Kidney Disease Outcomes Quality Initiative, British Renal Association, Canadian Society of Nephrology, European Best Practice Guidelines, and International Guidelines.

Definitions for the levels of evidence (I–IV) can be found at the end of the "Major Recommendations" field.

Guidelines

No recommendations possible based on Level I or II evidence

Suggestions for Clinical Care

(Suggestions are based on Level III and IV sources)

• Ensure regular testing and audit of water treatment system and quality of water produced for dialysis. Note some of the limitations to accurate chemical and microbial testing. Be familiar with local practice in municipal water treatment and testing procedures.
• Ultrapure water may reduce long-term risk of accelerated vascular damage, improve response to erythropoietic agents and reduce catabolic nutritional state.
• Infusion fluid for haemodiafiltration or haemofiltration must be produced with strict observance of the manufacturer's validated process. Final filtration must ensure 7 log reduction in bacterial count of ultrapure fluid.
• European guidelines should be the basis for optimal dialysate production.

Definitions:

Levels of Evidence

Level I: Evidence obtained from a systematic review of all relevant randomized controlled trials (RCTs)

Level II: Evidence obtained from at least one properly designed RCT

Level III: Evidence obtained from well-designed pseudo-randomized controlled trials (alternate allocation or some other method); comparative studies with concurrent controls and allocation not randomized, cohort studies, case-control studies, interrupted time series with a control group; comparative studies with historical control, two or more single arm studies, interrupted time series without a parallel control group

Level IV: Evidence obtained from case series, either post-test or pretest/post-test

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

• Optimal dialysate production
• Appropriate testing and audit of water used for hemodialysis in patients with end-stage kidney disease
• Reduction of long-term risk of accelerated vascular damage, improved response to erythropoietic agents, and reduced catabolic nutritional state

Not stated

Implementation and Audit

1. Establish affordable endotoxin testing capability in each state.
2. Standardise culture techniques. Encourage regular unit/state review of chemical and microbial test results.
3. Encourage provision of appropriate instruction to both medical and nursing staff regarding water treatment – as per both the Association for the Advancement of Medical Instrumentation (AAMI) and European Best Practice Guidelines (EBPG) guidelines.

Living with Illness

Effectiveness

• Water quality for haemodialysis. Nephrology 2005 Oct;10(S4):S75-7.



• Water quality for haemodialysis. Westmead NSW (Australia): CARI - Caring for Australasians with Renal Impairment; 2005 Jul. 7 p. [19 references]

Not applicable: The guideline was not adapted from another source.

2005 Oct

Caring for Australasians with Renal Impairment - Disease Specific Society

Industry-sponsored funding administered through Kidney Health Australia

Not stated

David Harris, Convenor (Westmead, New South Wales); Merlin Thomas (Prahran, Victoria); David Johnson (Woolloongabba, Queensland); Kathy Nicholls (Parkville, Victoria); Adrian Gillin (Camperdown, New South Wales)

All guideline writers are required to fill out a declaration of conflict of interest.

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI Institute on April 22, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.