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Hemodialysis Water: An Update on Safety Issues, Monitoring, and Adverse Clinical Events

Chronic hemodialysis patients are exposed to 15,000 to 30,000 liters of dialysate annually. This exposure is directly to the bloodstream, through a dialyzer membrane now usually of greater permeability than the original low-flux cellulosic types.1 Modern high-flux dialyzers extend not only the range of diffusible molecules, but also the potential for convective mass-transfer into the patient due to “back-filtration” of dialysate.2,3 Any compromise of the purity of the water used to make the dialysate may result in long-term toxicity,4 or occasionally acute severe morbidity or death.5–7 Safety standards for the quality of water used to make dialysate, and for the final dialysate itself, differ in various countries.8 In the U.S.A., the voluntary standards developed by the Association for the Advancement of Medical Instrumentation (AAMI) have undergone repeated revisions as specific concerns have increased.9–11 This review addresses some of the prominent concerns regarding the safety of the water and dialysate used in hemodialysis practice.