Water Sampling v2

STATEWIDE RENAL NETWORK
Haemodialysis
Water Sampling
Handbook
Version 2
Statewide Renal Network
Haemodialysis Water Sampling Handbook
The State of Queensland (Queensland Health) 2009.

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Version 2
Produced: September 2009
Statewide Renal Network Haemodialysis Water
Sampling Handbook, dated September 2009.
Scheduled review date September 2011.
Version 1
Produced: November 2007
Southern Area Health Service Haemodialysis Water
Sampling Handbook, November 2009.
Versions 1 & 2 published by
Production Services
Health Information Services
Darling Downs West Moreton Health Service District
Situated Toowoomba
Handbook
This Handbook has been created as part of the
Statewide Renal Network Water Standardisation
for Haemodialysis Units Project. It is for use
for Haemodialysis Unit staff to assist them in
Haemodialysis Water Sampling Procedures.
This handbook updated September 2009 with
funding from the Statewide Renal Network.
For rural and remote areas please see the
Remote Area Water Sampling Guidelines booklet.
Competencies
Two competencies are associated with this
Handbook Water Sampling and Water Result
Analysis. These can be accessed within the
Haemodialysis Unit.
Handbook Author
Robyn Bailey, Project Officer,
Acknowledgements
Queensland Nephrology Nurses
Network, Southern Area Health
Service Renal Network
Ms Judy March, Project Sponsor and
Executive Director of Nursing and
Midwifery Services at Darling Downs
West Moreton Health Service
District (Toowoomba & Darling
Downs)
Mr David Lawrie, Renal Technician
Darling Downs West Moreton
Health Service District (Toowoomba
& Darling Downs)
Mr Lionel Thring, Renal Technician,
Princess Alexandra Hospital
Ms Janine Jeffries, NUM Home
Haemodialysis, Princess Alexandra
Hospital
A/Professor James Petrie,
Nephrologist, Princess Alexandra
Hospital
Mr Henry Olszowy, Supervisor
Inorganic Chemistry, QHFSS
Mr Bruce Gray, Supervising Scientist
Public Health Microbiology, QHFSS
Ms Teresa Galos, Manager Central
Sample Receival QHFF
Ms Mary Hodge, Supervisor Organic
Chemistry, QHFSS
Statewide Renal Network staff
Production Services, Health
Information Services, Darling Downs
West Moreton Health Service
District (Toowoomba & Darling
Downs)
4
Reviewers
Ms Jenny Best, Pre-dialysis Educator,
Princess Alexandra Hospital
Ms Jennifer Boys, Renal Educator,
Royal Brisbane Hospital
Ms Kylie Dunbar-Reid, Renal Nurse
Educator, Cairns Base Hospital
A/Professor Carmel Hawley,
Nephrologist, Princess Alexandra
Hospital
Ms Angela Henson, Renal Nurse
Educator, Princess Alexandra
Hospital
Mr Roger Lawrence, Manager
Statewide Dialysis Services
Biomedical Technological Services,
Queensland Health
Ms Paula McLeister, Renal Nurse
Educator, Gold Coast Hospital
Ms Josie Skewes, Renal Nurse
Educator, Darling Downs West
Moreton Health Service District
(Toowoomba & Darling Downs)
Final Reviewers
A/Professor James Petrie
A/Professor Carmel Hawley
Janine Jeffries
Lionel Thring
Update July 2009
Keri-Lu Equinox, Project Officer,
Statewide Renal Clinical Network
History of Water Treatment in Dialysis by A/Professor James Petrie

If the water used for dialysis is not
correctly treated, serious problems can
result. In 1969 an outbreak of copper
poisoning was reported. The dialysis
water was deionised. Exhaustion of part
of the deionization bed led to the water
becoming strongly acidic. This leeched
copper out of the piping used in the
dialysis circuit, leading to haemolytic
anaemia and the death of at least one
patient1.
Water authorities routinely add chlorine
and ammonia to drinking water to
minimalise bacterial growth. The
chloramines formed can be removed
by carbon filtration, but as chlorine and
chloramines are dissolved gases they
cannot be removed by reverse osmosis.
Chloramines, like copper can cause
haemolytic anaemia. Kjellstrand et al
demonstrated adding ascorbic acid to
the dialysis concentrate neutralised
the chloramines, allowing dialysis to
proceed2.
In the late 1970s, two complications
appeared fracturing osteodystrophy
and dialysis dementia. Both proved
to be due to aluminium in the dialysis
water. Aluminium is added to the water
as a flocculating agent. It causes small
particles to precipitate, clarifying the
water3. Aluminium however is protein
bound. It will dialyse into a patient,
bind to transferrin, and not dialyse out
again. It can be highly toxic to bone
(causing osteodystrophy) and to brain
(causing dementia). It is effectively
removed by reverse osmosis.
Perhaps the most dramatic example

of aluminium toxicity occurred in
Eindhoven in Holland in 1976. A
dialysis unit in that town did not use
reverse osmosis. The dialysis fluid was
prepared insitu and warmed to blood
heat with an electric heater. The anode
of this heater was made of aluminium,
and over time it dissolved almost
completely, releasing the aluminium
into the dialysate. A major outbreak of
dialysis dementia ensued4.
The most recent major toxic event due
to dialysis water impurities occurred
in Caruaru in Brazil in 1996. Two
dialysis units received water from a
local reservoir. This water was heavily
contaminated by blue green algae
or cyanobacteria. One unit treated
the feed water fully, with filtration,
chlorination and reverse osmosis. No
problems occurred at this unit. No
effective water treatment occurred at
the second unit. 76% of the patients in
this unit died of liver failure. This liver
failure was caused by the microcystins
produced by the cyanobacteria5.
Water used for dialysis tends not to
be sterile. Most guidelines allow for
the use of water containing one or two
hundred colony forming organisms
per ml. This seldom produced adverse
effects in the short term. Water
containing even small numbers of
bacteria exposes patients to endotoxins
and leads to a chronic inflammatory
state. The use of sterile endotoxin free
water is associated in many studies
with improved patient outcomes.
5
REFERENCES
1
Matter, B.J., Pederson, J., Psiminos,
G. and Linderman, R.D. Lethal copper
intoxication in hemodialysis. Trans. Am.
Artif. Intern. Organs 1969; 15 309.
2
Kjellstrand, C.M., Easton, J.W.,

Yawawata, Y. et al. Haemolysis
in dialysed patients caused by
chloramines. Nephron 1974 13 427.
3
Alfrey, A.C., Mishel, J.M., Burks, J. et

al. Syndrome of dyspraxia and multiple
seizures associated with chronic
hemodialysis. Trans. Am. Artif. Intern.
Organs 1972: 18 257.
Flendrig, J.A., Jruis, H.G.H. Aluminium

intoxication the cause of dialysis
dementia? Proc.Eur.Dial.Transplant
Assoc. 1976; 13 355.
Jochimsen, E.M., Carmichael, W.W.,

Cardo, D.M. et al. Liver failure and
death after exposure to microcystins at
a hemodialysis centre in Brazil. N. Eng.
J. Med 1998; 338 873-878.
Contents
Water Treatment Plant ...................................................................... 8
Initial Testing ................................................................................... 8
Haemodialysis Water Guidelines .................................................... 10
Water Testing Schedule ................................................................... 12
Sampling Frequency ....................................................................... 13
Haemodialysis Unit Frequency ........................................................ 13
In Home/Community Haemodialysis Frequency ............................... 14
Bacterial Testing ............................................................................. 15
Endotoxin Testing ............................................................................ 19
Pesticide Testing ............................................................................ 23
Chlorine and Chloramine Testing .................................................... 26
Trihalomethane Testing .................................................................. 33
Calcium and Magnesium Testing .................................................... 37
Mercury Testing .............................................................................. 40
Heavy Metal Testing ....................................................................... 42
Standard Water Testing .................................................................. 45
Machine Testing ............................................................................. 47
References/Information Sources/Suggested Readings ................... 48
Water treatment Plant

The first step of installation of a water
treatment plant for haemodialysis
commences with the sampling of water
from the site where it is expected
the water treatment plant will go. It
is necessary to know the quality of
the water that will be supplied to the
unit to identify the type of treatment
plant that will be required. All aspects
need to be taken into consideration
including possible seasonal changes
or contamination due to human
intervention.
If water is supplied from a municipal
water supply (e.g. Council supply) it will
already meet drinking water guidelines
for Australia as per the NHMRC
Australian Drinking Water Guidelines1.
Refer to Table 2 -Drinking Water
Guidelines and Haemodialysis Water
Guidelines Comparison - American
Association of Medical Instrumentation2
(AAMI) European Guidelines (EP)3 and
2006 Draft International Standards
Organisation (ISO) Fluids for
Haemodialysis and Related Therapies
Guidelines4.
Initial testing
Initial water testing of the source water
should include the following tests:
Bacteria and Endotoxin
Pesticide
Mercury
Lead
Trihalomethanes
Standard Water
Calcium & Magnesium
Anions & Cations / Heavy Metals /
pH & Conductivity
8
On return of the water tests (which

can take up to six weeks in the case of
pesticides depending on the testing
facility used) the water treatment plant
can be designed. It is necessary to plan
and design a pre-treatment plant that
will remove or reduce the contaminants
in the water to an acceptable level for
haemodialysis.
When planning the haemodialysis
water treatment plant and distribution
loop there are many specifications
to take into consideration. It is
recommended that the distribution
loop is a continuous loop, has no dead
ends, decreases stagnant areas by
limiting the use of branches5,6 and the
loop conserves water where able5.
Disinfection of the loop is required
to decrease the risk of bacterial or
endotoxin contamination affecting
the haemodialysis patients. Heat
disinfection is a relatively inexpensive
and practical method of disinfecting
the water plant and distribution loop
although it will not remove biofilm1.
The routine most commonly used
is daily, however second daily and
three times per week can achieve
guidelines results. While it is important
to ensure bacterial and endotoxin
contamination does not occur it is
also necessary to ensure water usage
is kept to a minimum. It is suggested
that the routine of heat disinfection
to be utilised is at the time period
that ensures achievement of adopted
guideline. If guidelines are not being
met then an increase in the disinfection
routine is required7.
Refer to the manufacturers

recommendations regarding
disinfection techniques although
generally the water temperature used
should be greater than 85C8 and
disinfection should run for a period
of thirty minutes5 at the desired
temperature.
Polyvinyl chloride (PVC)5 and
Polyethylene (PEX)5,9 are two of the
common and preferred materials for
haemodialysis water treatment with
stainless steel and titanium blend used
in distribution loop systems.
PEX is able to withstand high
temperatures and has a smooth inner
surface9 and PVC is used throughout
the United States due to cost limiting
factors of other materials5. PVC is not as
tolerant to high temperatures as some
of the other piping such as PEX.
It is important to ensure that no
piping is used that is made from toxic
Material
materials in haemodialysis water

plants or distribution loops due to the
ability of the purified water to affect
these materials and thus contaminate
the water. These toxic materials
include copper, lead, zinc, brass
and aluminium5. Soldering can also
adversely affect the haemodialysis
water treatment plant by dropping
flux into the inner aspect of the piping
causing contamination of the water
supply. It is necessary to ensure that
trained personnel undertake repairs
or changes to the distribution loop or
water treatment plant.
Flow or scrubbing velocities of the
distribution loop also needs to meet
criteria to ensure the risk of biofilm
adherence inside the loop piping
is decreased. Permeate should
travel through the distribution loop
at approximately one metre per
2.3 seconds.
Bleach
Peracetic Hot Water
(Sodium Hypochlorite)
Acid
Polyvinylchloride (PVC)
Cross-linked Polyethylene(PEX)
Stainless Steel
Polypropylene
Polyethylene
Table 1. Common disinfectants and piping materials compatibility. Adapted from

Table B.1 International Standards Organisation Draft Guidelines 2006, Fluids for
Haemodialysis and related therapies.
9
Haemodialysis Water Guidelines

Water Guidelines have been designed
to ensure quality haemodialysis water
is delivered to dialysis machines no
matter where patients dialyse.
While the AAMI and EP guidelines are
not Australian they have been adopted
by most Australian haemodialysis units.
In Australia the Caring for
Australians with Renal Impairment
(CARI) guidelines have not made
recommendations as AAMI and EP
have. The reason for this is that
Level I or II evidence for water quality
haemodialysis standards is lacking.
Although the CARI group has made no
guidelines it has made suggestions for
clinical care.
The CARI group have recommended:
1. Ensure regular testing and
auditing 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 11.
10
2. Ultrapure water may reduce longterm risk of accelerated vascular

damage, improved response to
erythropoetic agents and reduce
catabolic nutritional state 11.
3. Infusion fluid for haemodiafiltration
or haemofiltration must be produced
with strict observance of the
manufacturers validated process.
Final filtration must ensure 7 log
reduction in bacterial count of
ultrapure fluid 11.
4. European guidelines should be
the basis for optimal dialysate
production 11.
CONTAMINANT
AAMI2
Maximum
limits (mg/L)
European3
Maximum
limits (mg/L)
*Australian
Drinking Water
Guidelines1 mg/L
Aluminium
Ammonium
Antimony
Arsenic
Barium
Beryllium
Cadmium
Calcium
Chloramines
Chloride
Free Chlorine
Total Chlorine
Chromium
Copper
Fluoride
Heavy Metals
Lead
Magnesium
Mercury
Nitrate
pH
Potassium
Selenium
Silver
Sodium
Sulphate
Thallium
Trihalomethanes
Zinc
0.01
0.01
0.20
0.006
0.005
0.1
0.0004
0.0010
2.00
0.2
0.006
0.005
0.1
0.0004
0.0010
2
0.10
0.003
0.007
0.7
0.002
200
50
0.50
0.014
0.10
0.20
0.005
4.0
0.0002
2.00
`
8
0.09
0.005
70
100.0
0.002
< 0.008
0.10
1.0
0.014
0.20
0.10
0.005
2.00
0.001
2.00
2.00
0.09
0.005
50
50
0.002
0.10
5.0
0.05
2.0
1.5
0.1
0.001
50
6.5-8.5
0.01
0.1
180
500
0.25
3
Table 2. Guideline Comparison.

11
CONTAMINANT
AAMI
European
Singapore12
Maximum Pharmacopoeia Maximum
limits
Max. limits
limits
Japan Society for

Dialysis Therapy
Max. limits
EDTNA/ERCA
Maximum
limits
ISO 2006 Draft4
Bacteria
200 cfu/ml
100 cfu/ml
200 cfu/ml
100cfu/ml
100 cfu/ml
100 cfu/ml
Endotoxins
2EU/ml
0.25EU/ml
5 EU/ml
0.25 EU/ml
0.25 EU/ml
0.25 EU/ml
Fungi and Yeast
10 cfu/ml
Table 3. Bacterial and Endotoxin Comparison Table for

Haemodialysis product water (permate)1,2,3,4,12.
Water Testing Schedule
Once a water treatment plant is
commissioned it is necessary to
routinely test the water prior to
commencement of any haemodialysis
occurring and in an ongoing routine.
It should be remembered that water
testing results will not be available
immediately (can take up to 14 days for
return of results) and this time delay
should be considered before booking
patients for haemodialysis when
commissioning a haemodialysis water
plant.
For at least the first three months when
commissioning a new water plant
bacterial and endotoxin testing should
occur weekly from multiple points
throughout the system:
1. Post reverse osmosis unit
2. Dialysate
3. End of distribution loop
If bacterial and endotoxin levels
exceed the recommended level then
a thorough chemical disinfection of
the water plant and distribution loop
is necessary. It may also be necessary
to increase the points where water
tests are taken to pin point the area of
possible contamination.
12
After the initial validation of the

water plant has occurred ongoing
routine testing should occur at least
monthly5,24,27,28 for a three month period
and then move to every three months.
Bacterial and Endotoxin testing
continues monthly both post Reverse
Osmosis water and dialysate. Ongoing
water sampling is then required to
reduce the risk to haemodialysis
patients a sampling frequency regime
has been adopted.
Sampling Frequency
The Sampling Frequency section has
been compiled using current knowledge
and acceptability and incorporates the
needs of rural and metropolitan centres
and those that have a blending of both.
Changes will occur over time.
Frequency may need to be changed
due to seasonal and environmental
variations of the specific area e.g.
cotton industry increases aerial
spraying from September to November
requiring increased sampling for
pesticides during this period.
Harvesting can also cause materials to
become air-borne increasing pesticide
contamination of the surface water.
HAEMODIALYSIS UNIT FREQUENCY

Legend for Table 4 Haemodialysis Unit
Frequency for water sampling.
A Chlorine testing should also occur
before each dialysis or dialysis shift.
Chlorine testing can occur using:
DPD 4 tablets
Combination DPD 1 and 3 tablets
Chlorometer or Photometer
B Water Hardness testing should occur
Water hardness can be tested using:
Yes/No tables
Testing strips
When using hardness or chlorine
testing methods refer to manufacturers
information sheets provided for testing
method. Validation of chlorine and
hardness tests needs to occur routinely
using an independent testing centre.
Collection
Point/Sample
Bacteria
Counts
Endotoxins
Pesticides*
Chlorine &
Chloramine
THMs
Calcium &
Magnesium
Auslab Codes
HPC
DWPEST
DCLNH
THM
DCAMG
Feedwater
Post Carbon
Post dialysis
machine
Collection
Frequency
Bacterial
Counts
Endotoxins
Pesticides*
DHMSA (feed)
HGFW (feed)
DPROW (post RO) HGRO (post RO)
Standard
Water Analysis
DSWA
pH/Cond
THMs
Calcium &
Magnesium
Heavy
Metals
Mercury
Standard
Water Analysis
3 Monthly
(4 x year)
6 Monthly
(2 x year)
Chlorine &
Chloramine
Predialysis
Monthly
Mercury
Post Softener
Post RO
Heavy
Metals
Annually
(1 x year)
Rural
Metro
Table 4. Haemodialysis Unit Sampling Timetable.

13
IN HOME/COMMUNITY HAEMODIALYSIS
FREQUENCY
Legend for Table 5 In Home/Community
Haemodialysis Unit Frequency for water
sampling.
C Chlorine testing should also occur
Chlorine testing can occur using:
DPD 4 tablets
Combination DPD 1 and 3 tablets
Chlorometer or Photometer
D Water Hardness testing should occur
Water hardness can be tested using:
Yes/No tables
Testing strips
When using hardness or chlorine

testing methods refer to manufacturers
information sheets provided for testing
method used.
Validation of chlorine and hardness
tests needs to occur routinely using an
independent testing centre.
E Rural areas
F Metropolitan Areas
G Where resources allow
H Minimum
Collection
Point/Sample
Bacteria
Counts
Endotoxins
Pesticides*
Chlorine &
Chloramine
THMs
Calcium &
Magnesium
Auslab Codes
HPC
DWPEST
DCLNH
THM
DCAMG
Feedwater
Post Carbon
Post dialysis
machine
Collection
Frequency
Bacterial
Counts
Endotoxins
Pesticides*
Chlorine &
Chloramine
THMs
Predialysis
DHMSA (feed)
HGFW (feed)
DPROW (post RO) HGRO (post RO)
Standard
Water Analysis
DSWA
pH/Cond
3 Monthly
(4 x year)
1st
3 mths
6 Monthly
(2 x year)
Annually
(1 x year)
Calcium &
Magnesium
Heavy
Metals
Mercury
Standard
Water Analysis
Monthly
1st
3 mths
Table 5. In home/community haemodialysis sampling timetable.

14
Mercury
Post Softener
Post RO
Heavy
Metals
SAMPLING
Sampling methodology may change
over time as new equipment and
procedures change please refer to
Queensland Health Scientific Services
(or independent testing facility) to
ensure containers listed are current.
Bacterial testing
Bacteria occur naturally in water
sources but can also be introduced
or occur due to reduced water flow.
This is significant in the planning and
designing of haemodialysis units and
associated plumbing as biofilm can
adhere to surfaces such as piping,
hoses, dialysate bottles and inside
dialysate machines15,16.
Guidelines for Bacterial counts
are designed to ensure quality
haemodialysis water is delivered to
dialysis machines. To ensure the correct
machine disinfection process occurs
water sampling is required. Water
sampling is used as a validation tool for
the disinfection process.
Microbiological testing should occur
at least once per month testing both
reverse osmosis water and dialysate
for in-centre units and monthly to
three monthly for home/community
haemodialysis (dependant upon
resources).
Maximum microbial contamination of
Haemodialysis Permeate should be
<100 cfu/ml and maximum microbial
contamination of dialysate should be
<25 cfu/ml with a suggested action level
of 50 cfu/ml5.
Samples to be collected and tested at

points expected to have the highest
bacterial load1 or lowest water flow.
These testing points should be:
1. Feed supply water tap (Water)
2. Post carbon (Water)
3. Post RO (Permeate)
4. Post dialysis machine (Dialysate)
If routine sampling points identify an
elevated result then increased testing
is required using the following testing
points:
1. Feedwater
2. Post pre-treatment (softener and
carbons)
3. Post UV irradiation (if applicable)
4. Post RO
5. Start of distribution loop
6. Random outlets on loop
7. End of loop
8. Post machine
9. Dialysate
Once testing has occurred and results
are available they will need to be
reported to the appropriate personnel.
If the results are greater than the
guidelines then disinfection and
increased monitoring may be required.
15
Sampling
The bacterial samples should be
collected in a 120ml container with
sodium thiosulphate already added.
These containers can be supplied by
the testing centre.
Once collection occurs ensure the label
on the container is completed with as
much information as appropriate.
The test carried out is called the

heterotrophic plate count (HPC).
Samples for bacterial counts are
inoculated onto agar plates and
incubated @ 360C for 40 to 48 hours
before being counted and then reported
in colony forming units.
Note: Bacterial samples should be
taken after testing for heavy metals and
pesticides as the ethanol spray (used
for bacterial and endotoxin testing) can
adversely effect the other water sample
results.
16
Sampling procedure
Step 1. Ensure the correct testing point
is chosen with the correct preparation
of port or collecting point.
Should a tap be used for sample
collection the tap will require
disinfection prior to the collection
of the water sample. The tap, where
possible, should be soaked in a
70-90% ethanol solution.
At least two litres of water should be

run through tap at a high flow before
taking mid stream water samples from
the disinfected tap.
Should a port be used the port will

require disinfection using 70-90%
ethanol solution in a spray container.
Wait a minimum of two to three minutes
before taking the required sample.
This waiting period allows the ethanol
solution to evaporate otherwise the
ethanol will falsely affect the test
results.
Step 2. Ensure the label on the

container is completed with as much
information as is appropriate.
Sender: This is the unit sending the
sample.
Source: The source of the sample i.e.
where it is collected from.
Sample: UR number generated by unit
and inputted by pathology
department.
Date:
Date sample collected in
dd.mm.yy format
Number: Batch number of samples
sent.
Time:
Time sample taken using
24 hour clock
Example: 2100hrs (9pm).
Label example:
Should the dialysate connector (Hansen

connectors) be used for sampling the
connectors will require disinfection
using 70-90% ethanol solution in a
spray container. The dialysate should
be run through the connectors by
initiating dialysate flow. Allow at least
200mls to flow through connectors
prior to taking a mid stream sample.
BACTERIOLOGICAL
WATER SAMPLES
Sender: Toowoomba Renal Unit
Source: Toowoomba Town Supply
Sample: RENTW Date: 10.05.07
Number: TWH 126 Time: 0630hrs
17
Step 3. Ensure the form is completed with as much information as is appropriate.

Form example:
Toowoomba Renal Unit
(07) 4616 6167
RN Smith
RN Smith
10/05/07
6167
P.B.No : (Insert Batch number)

G.C.L.ID.No : (Bottle ID Number)
RN Smith
RN Smith
10/05/07
0630 hrs
Inserting information such as collector name and phone number can be helpful
to the testing centre as they can feedback any problems with testing the sample
or if further information is required prior to testing the sample provided. This
information can help reduce the number of samples discarded and not tested.
18
Step 4. Ensure the sample is

forwarded to the testing centre within
the correct time period, ensuring it
is stored and transported under the
correct conditions.
Bacterial samples need to reach the
testing point within 12 hours (as per the
International Standard) with the sample
being kept between 2 and 80C during
transportation (i.e. with ice bricks).
Do not freeze samples.
Report
Results will be reported into Auslab by
the testing facility or communicated to
the unit by the process which has been
previously determined.
Bacterial results are reported as
Heterotrophic Colony Count in Colony
Forming Units per mL at 360C.
Action required after result received
will depend on if the result is within or
outside the Guideline.
Flowchart 1.0 shows possible actions
of Bacterial or Endotoxin tests that are
above adopted guidelines. Refer to your
own units disinfection processes.
Endotoxin testing
Endotoxin is the toxic byproduct of
gram negative bacteria including
pseudomonas, flavobacterium,
enterobacter, achromobacter,
aeromonas, serratia, moraxella and
alcaligenes 15,16 which have adapted to
survive in water15. Endotoxins can be
present in source water or can occur

during the bacterial breakdown process
that occurs post disinfection or post
ultraviolet radiation.
Guidelines for endotoxin counts
are designed to ensure quality
haemodialysis water is delivered to
dialysis machines. To validate correct
machine disinfection processes occur
water sampling is required.
Endotoxin testing should occur at least
once per month testing both reverse
osmosis water and dialysate and
monthly to three monthly for home/
community haemodialysis (dependant
upon resources).
Results should be within adopted
guidelines < 0.25EU/ml for permeate
and < 0.03 for dialysate3.
Samples to be collected and tested at
points expected to have the highest
bacterial load1 or lowest water flow.
Routine testing points should be:
1. Post RO
2. Post dialysis machine
Note: Endotoxin testing is not
performed by CaSS. An agreement
for endotoxin testing needs to occur
between the individual unit and the
testing facility.
19
Flowchat 1.0 Problem Solving Flow Chart for Positive Bacterial/Endotoxin Test
Routine samples taken - positive result
received
Positive Endotoxin/Bacterial Test noted
Identify where possible contamination is

by increasing sampling points. This is
dependant on the first sampling point.
Work from pre-treatment to machine or

machine to end of loop depending on
where contamination has been highest.
Increased sampling points include:
1. Feedwater (bacterial only)
2. Post pre-treatment (softener and carbons)
4. Post reverse osmosis
7. End of loop
8. Post machine
9. Dialysate
Contamination point identified
Machine identified
Outside machine identified
Disinfect machine using different

disinfection technique
Change disinfection loop or reverse

osmosis membrane using different or
alternate method of disinfection
Retest
Retest positive
Retest
positive?
Retest
positive?
Yes
No
Check and change as appropriate:
1. Hoses
2. Ultrafilter
3. Dialysate delivery lines
Change disinfection routine for machine

utilising varied or alternate method
disinfection techniques
20
Yes
No
Review and alter (as appropriate)
chemical disinfection technique and
dwell times
Change disinfection routine for loop or

reverse osmosis membrane utilising
varied or alternate method disinfection
techniques
If routine sampling points identify an

elevated result then increased testing
is required using the following testing
points:
2. Post RO
5. End of loop
6. Post machine
7. Dialysate
If the results are greater than the
guidelines then disinfection and
increased monitoring may be required.
Sampling
The endotoxin samples should be
collected in a yellow capped sterile
polystyrene specimen container or a
glass container depending on testing
centres requirements. Refer to your
testing facility for the container they
require. Borosilicate glass tubes are
the gold standard. Polypropylene
containers are not recommended as
endotoxins are known to stick to the
polypropylene material.
The endotoxin samples are not
available through QHSS - a local
arrangement needs to occur between
the testing facility and haemodialysis
unit.
Testing Technique
The sample is tested by Limulus
Amebocyte Lysate (LAL) Testing
techniques. LAL Testing includes
Gel clot, Kinetic Chromogenic
or Chromogenic and endpointturbidimetric technique13. The test
requires three to tens mls of water post
reverse osmosis unit or dialysate to be
tested13.
The LAL gel clot method gives a positive
or negative reading to a particular
endotoxin sensitivity in endotoxin
units (EU) per ml. The single test vial is
marked with its endotoxin sensitivity.
For example if the LAL tubes endotoxin
sensitivity is 0.25 EU/ml and the test is
negative the result is reported as < 0.25
EU/ml. If the same test is positive the
report would state the result is > 0.25
EU/ml13.
LAL gel clot comes with product control
(PPC) to be tested with each batch to
validate the methodology of testing13.
21
Sampling procedure
See for Step 1 Bacterial sampling for
preparation of tap, port or Hansen
connectors.
Name:
The source of the sample
i.e. where it is collected
from.
Specimen: The sample type
Sender: This is the unit sending the
sample.
Date:
Date sample collected in
dd.mm.yy format
Time:
Time sample taken using

24 hour clock
Example: 2100hrs (9pm).
DOB:
Not required for this
sample.
Number: Auslab number allocated to
this source.
Label example:
SPECIMEN CONTAINER
Name
Post RO
Specimen Permeate
Sender
Toowoomba Hospital
Renal Unit
Date 10.05.07
Time 0630 hrs
DOB
No.

Form example:
(07) 4616 6167

RN Smith
RN
10/05/07
Post RO
EU
6167

22
RN Smith
10/05/07
RN
0630 hrs
Step 4. Ensure the sample is forwarded

to the testing centre within the correct
time period, ensuring it is stored and
transported at correct conditions.
Endotoxin samples need to reach the
testing point within 24 hours with
the sample being kept at 40C during
transportation (i.e. on ice).
Do not freeze the sample.
Report
Results will be reported onto Auslab by
Endotoxin results are reported as
Endotoxin Units (EU) per ml.
Action required after result received
will depend on if the result is within or
outside the Guideline.
Flowchart 1.0 shows possible actions
of Bacterial or Endotoxin tests that are
above adopted guidelines. Refer to your
own units disinfection processes.
Pesticides can be removed from the

haemodialysis water by activated
carbon and the intact reverse osmosis
membrane.
Sampling
When testing for pesticides and
herbicides water testing from the
following sample points and sample
types are required on a 6 monthly
basis:
Water from the Feed supply
Permeate from post reverse Osmosis
Unit
Please note season variations will
dictate more frequent sampling
requirements. No pesticides or
herbicides should be present in
haemodialysis permeate.
The samples should be collected in a
1000ml (one litre) amber coloured glass
solvent washed bottle (pictured). This
sample requires no additive.
Pesticide Testing
Pesticides include herbicides,
insecticides, nematicides, rodenticides
and miticides1 and occur in water due to
rural or metropolitan pesticide usage.
Pesticide overexposure is linked to
symptoms of headache, dizziness,
convulsions, heart muscle irritation,
liver irritation and death15 while
exposure to herbicides have been
noted as twitching, muscle paralysis
and loss of sexual function15.
23
Sampling procedure
Step 1. Ensure the correct testing point is chosen and container is filled without
overflowing.
Step 2. Ensure the label on the container is completed with as much information
as is appropriate.
Unique Sample Identification Number:
Unit identification number set up with Auslab.
Preservatives Added:
Nil required for Pesticide testing
Preservative Batch Numbers:
Not applicable
Analysis Required:
Test required for this sample
Date Sealed:
Date sample collected in dd.mm.yy format
By:
Samplers name
Q.H.S.S. Batch Number:
Number of batch
Q.H.S.S. Identification Number: Number allocated by QHSS when sample received
at their testing facility
Local Authority:
Council that supplies water for unit or machine
Sample Point:
Site where water sample from
Owner/Address:
Renal Unit or Home address
Label example:
SOLVENT - WASHED
Unique Sample Identification Number: RENTW Preservatives Added: Nil
Preservative Batch Numbers: Not applicable
Analysis Required: Pesticide screen
Date Sealed:
10.05.07
By:
1524
Q.H.S.S. Identification Number:

Local Authority: Toowoomba Town Supply
Sample Point:
Feedwater
Owner/Address: Toowoomba Hospital Renal Unit
24
R.N. Smith

Form example:
(07) 4616 6167

RN Smith
RN
10/05/07
6167

RN Smith
10/05/07
RN
0630 hrs

Keep sample chilled (on ice) post
collection and during transportation.
Do not freeze.
Report
Pesticide results will be reported as
g/L. (Guideline and Health values
compared to reporting limits).
There should be no pesticides or
herbicides present in haemodialysis
product water (permeate).
25
Chlorine and Chloramine testing

Bacterial contamination of water is
a large concern for all Councils and
Haemodialysis Units. Bacterial levels
are decreased in water supply by
adding chlorine as a disinfectant. This
usually occurs when the local Council
treats the drinking water supply with
chlorine in gas form. This gas when
mixed with water creates strong
biocidal properties1,14. The amount
of chlorine added to the water varies
on individual council requirements.
Although chlorine has these biocidal
properties the effect does diminish
over time. This decrease in the level
of chlorine in the water therefore
increases the risk of bacterial growth
occurring. To combat the diminishing
effects of chlorine councils also add
ammonia to the water. This ammonia
and chlorine interaction causes the
formation of chloramines to occur and
as such councils have a longer term
bacterial measure. Chloramine levels
dont dissipate in the water and as such
need to be effectively removed from the
haemodialysis dialysis water supply1,14.
While chlorine and chloramines may
be good disinfectants for use in water
treatment it is damaging to the red
blood cells should it come into contact
with a haemodialysis patients blood.
If chlorine or chloramines are in the
dialysate a dark blood appearance
can be seen in the blood lines leading
away from the dialyser. Patients
may exhibit symptoms of shortness
of breath, headache, palpitations,
vomiting, haemolysis followed by
26
anaemia, methemoglobinemia and

possibly death 5,15,17. The formation
of methemoglobin means that the
transport of oxygen or carbon dioxide
cannot occur causing cyanosis and
hypoxic symptoms for the patient.
Methemoglobin also leads to the
formation of Heinz bodies 17,18,19.
While Heinz bodies are an indicator of
chloramine water contamination they
are not present for long in the patients
blood stream due to the actions of
the spleen. They will be present in the
blood stream longer for patients with
splenic dysfunction.
Chlorine and chloramines are removed
from the haemodialysis water by carbon
filters.20,21 Since these are dissolved
gases they are not removed by reverse
osmosis. Ascorbic acid added to the
dialysate has also been known to
absorb chloramines20. Refer to WPI
000014 for Ascorbic Acid Additive to
Neutralise Dialysate Chlorine.
Contaminants such as chlorine can
compromise the integrity of the
reverse osmosis membrane causing
the delivery of chloramines and other
contaminants to the client. Chlorine
is easily absorbed by carbon filters
while a longer contact time is required
to remove chloramines from the
water. This has been estimated at a
minimum requirement of six minutes
for free chlorine and ten minutes for
chloramines14.
The importance of careful testing for
chlorine and chloramines cannot be
stressed enough.
Chlorine levels should be checked

before each patient dialysis, or if incentre, before each patient shift post
carbon filters. It will depend on the
configuration of the pre-treatment to
which carbon filter this should be taken
from preferable post worker carbon or
carbons (pre-polisher carbon).
For accuracy of the reading the pre
treatment will have needed to be
running for at least fifteen minutes
prior to test being taken. Testing for
chlorine and chlorines is done within
the dialysis unit using:
DPD4 tables
A combination of DPD 1 and 3
Chlorometer/Photometer (Highly
Recommended and preferred
method).
Permeate levels of Total Chlorine
should not exceed 0.1 mg/L. No
patients should dialyse on PERMEATE
from REVERSE OSMOSIS UNIT reading
0.1mg/L or higher2,3,4,11.
To effectively remove chlorine and
chloramines from haemodialysis water
activated carbon filters are required.
Ascorbic acid can be added to dialysate
as an interim measure to help with
chlorine breakthrough.
To ensure adequate removal at least
two carbon adsorption beds/vessels
(with a sampling tap between)
installed in a series configuration is
recommended. The carbon minimum
iodine rating of 900 is required. Each
adsorption bed will require an Empty
Bed Contact Time (EBCT) of minium
5 minutes (i.e. minimum ten minutes
EBCT for two vessels) at the maximum

product water flow rate.
The carbon media size required is that
which successfully adsorbs chlorine
and chloramines from the feed water
supply without compromising water
quality with bacterial growth by over
sizing the carbon vessels.
Larger carbon vessels have been linked
to bacterial growth in some facilities
while smaller carbon vessels can
encourage channelling of the carbon
media. The use of carbon filters that
have backwashing capabilities is
recommended.
Chlorine/chloramine reading may be
elevated post Reverse Osmosis Unit if:
1. Feed supply water chlorine/
chloramine level is elevated
this can occur if the Council has
increased the dosing of chlorine due
to bacterial problems with the water.
2. Carbon filter clogging or related
problems:
* Exhaustion or adsorption rate of
the carbon media.
* Filter is in bypass
* Channelling of carbon filter has
occurred
* Nitrified bacteria present within
the carbon filter
* Contact time not sufficient to
reduce chlorine/chloramine (can
be due to the demand being
greater and reducing the contact
time the water has with each filter)
27
1. Increased chlorine level of feed

supply
It is recommended for the
Haemodialysis Unit to have a good
relationship with the local Council
as well as a reporting method where
the local Council can notify the
haemodialysis staff of any irregularities
in the water supply. This would allow
forward notification of elevated chlorine
levels noted from the water as it leaves
the Council reservoir.
As chlorine dissipates with time a
reservoir positioned before the pretreatment may allow for the chlorine
levels to drop prior to the water being
treated by the haemodialysis units.
This reservoir method tends to work if
chlorine gas is elevated as it allows the
dissipation of this gas. This method
will have bacterial contamination risks
and will need careful planning and
decision making as specific tank sizes
will be required and the type of chlorine
contamination will affect this.
Extensive discussions would be
required with the Director of the unit,
the facility plumbers, engineers and
pre-treatment service providers.
2. Carbon filter clogging or related
problems.
a) Exhaustion or absorption rate of the
carbon media.
Diagnosis:
This problem is diagnosed by daily
testing of the effectiveness of the
carbon media.
Daily testing using DPD tablets or
chlorimeter/photometer.
28
Procedure:
These filters are backwashed one at a
time when dialysis has been completed
for the day. The backwashing process
fluffs up the carbon decreasing
clumping of the carbon fibres and
increasing the surface area available.
Backwashing can cause problems post
carbon filter as fines can be released
into the water once the carbon filters
have completed backwashing. These
fines need to be stopped before
progressing to the RO membrane with
the use of smaller micron filters post
carbon and pre reverse osmosis unit.
If elevation of chlorine or chloramines
occurs after backwashing has occurred
then the carbon media may be
exhausted and require rotation and
replacement of the carbon media.
b) Filter is in bypass ensure the
appropriate carbon filters are not
bypassed.
Note: The polisher or last carbon filter
should never have the capability of
being bypassed.
Diagnosis:
This problem is diagnosed by
observation of the taps on the piping
between or above the carbon filters.
Procedure:
The taps should be opened to ensure
the appropriate carbon filters are being
utilised.
c) Channelling of carbon filter has

occurred.
Diagnosis:
This problem is diagnosed by daily
testing of the effectiveness of the
carbon media.
Daily testing using DPD tablets or
chlorimeter/photometer.
Procedure:
Backwashing of the filter is required as
per Exhaustion or adsorption rate of the
carbon media.
d) Nitrified bacteria present within the
carbon filter.
Diagnosis:
Water samples to be taken post carbon
filters for total organic carbon (TOC)
or dissolved organic carbon (DOC
- through an 0.45 micron filter).
Procedure:
The carbon vessel will need to be
emptied and disinfected with the
appropriate solution. Discussion will
then need to occur about the type and
amount of carbon that will need to fill
the vessel to decrease the chance of
reoccurrence.
Re-evaluation of particle filtration
method would be required in this
instance.
e) Contact time not sufficient to reduce

chlorine/chloramine (can be due
to the demand being greater and
reducing the contact time the water
has with each filter)
Diagnosis:
Ongoing and increasing chlorine
levels post carbon filters i.e. chlorine
breakthrough.
Procedure:
Empty Bed Contact Time (EBCT) needs
to be re-evaluated.
EMCT Calculation = (7.48 x V)
Q
V = Volume of particles in the bed (ft3)
and
Q = flow rate of water through the filter
(gal/min)
Easy guide to EBCT is:
Volume of carbon (in litres)
flow (in litres/min)
eg: The BTS portable water trolleys
use two 14 litre capacity cylinders,
which are each part filled (to allow for
backwashing) with 10 litres of carbon.
At a flow of 2 litres/min (maximum
expected for a portable RO and a
dialysis machine running at 500 ml/
min), this gives an EBCT of 5 minutes
per cylinder, for a total of 10 minutes.
29
Flowchat 2.0 Action for Elevated Chlorine/Chloramine Levels

Elevated Chlorine/Chloramines noted
Identify problem
Increased chlorine/chloramine level in

feed water
Discussions with Council re: chlorine/
chloramine increase in water supplied to
haemodialysis unit
Discussions required re: pre-treatment
requirements to cope with increase in
feedwater chlorine/chloramine levels
should this be an ongoing problem
Carbon clogging or related problems
Identify problem
Nitrified bacteria
Filter bypassed
Carbon filter to have

carbon removed and
appropriate
disinfection. New
carbon required.
Ensure filter online
Carbon exhaustion,
saturation or
channelling
Backwashing
required
No
Improvement?
Discussions required
Yes
Review of particle
filtration method
required
Discussions required
Review carbon
change protocol.
Review carbon
material type.
Review empty bed
contact time.
Review number of
carbon filters.
30
Ensure regular
backwashing
procedure during
unit downtime
Sampling
When testing for chlorine or
chloramines water testing from the
types is required on a 3 monthly basis:
Water post carbons (or a specific
carbon number depending on unit
design)
The samples should be collected in
a 250ml detergent washed bottle
(pictured). This sample should be kept
out of sunlight in a well sealed bottle.
Sampling procedure
is chosen.
Step 2. Collect sample by filling the
container half full with water from
testing point and discard. Fill container
again to the top with water from testing
point and discard. The third fill will be
the sample collection. Ensure container
is filled but not overflowing.
Details required on this label are the
same as the Pesticides label.
Label example:
DETERGENT - WASHED

Analysis Required: Total Chlorine and Chloramine level
Date Sealed:
10.05.07
By:
R.N. Smith
0794

Sample Point:
Feedwater
31

Form example:
(07) 4616 6167

RN Smith
RN
10/05/07
6167

RN Smith
10/05/07
RN
0630 hrs

Do not freeze. Keep out of sunlight.
Note: Analysis to occur within 48 hours
of sample collection with 6 hours
being ideal where possible. If organic
matter is in the water the chlorine and
chloramine testing needs to occur
immediately.
32
Organic matter can be identified

by running 60mls of the water from
sampling point through a 0.45micron
filter. Elevated bacterial levels also
indicate the presence of organic matter.
Report
Chlorine and Chloramine results will be
reported as mg per litre.
Trihalomethane testing
Haemodialysis water should be
free from carcinogenic by-products.
Haemodialysis Water post carbon
filter should be Trihalomethane free.
Chlorine gas added to water creates
hypochlorous acid which takes
electrons from organic materials
creating a carcinogenic by-product
called Trihalomethane (THM)1. When
testing for Total Trihalomethane
(TTHM) the sample is tested for
the four components of TTHM
Trichloromethane (chloroform),
Tribromemethan (Bromoform),
Bromodichloromethane and
Dibromochloromethane.
The monitoring of Trihalomethane
(THM) levels in haemodialysis water is
required to ensure the effectiveness of
the carbon filters. Elevated THM levels
indicate exhaustion or saturation of
the carbon vessels. Trihalomethane
levels for dialysis patients should be
less than one tenth of drinking water
specifications using US EPA drinking
water standards2. THM levels should
not exceed 8g/L2.
CONTAMINANT
Australian Drinking
Water Guidelines1
US EPA
Drinking Water
Guidelines22
Haemodialysis
Guideline2
Trihalomethanes
250g/L
0.25mg/L
80g/L
0.08mg/L
< 8g/L
Table 6. THM Guidelines1,2,22.
33
To effectively remove THMs from

haemodialysis water activated carbon
filters are required. To ensure adequate
removal of THM at least two carbon
adsorption beds/vessels (with a
sampling tap between) installed in a
series configuration is recommended.
The carbon minimum iodine rating
of 900 is required. Each adsorption
bed will require an Empty Bed Contact
Time (EBCT) of minium 5 minutes (i.e.
minimum ten minutes EBCT for two
vessels) at the maximum product water
flow rate. This carbon configuration,
EBCT and water flow rate will
successfully remove THMs.
Monitoring of THM levels in
haemodialysis water alerts the user to
a possible Chloramine breakthrough/
exhaustion of carbon tank.
Sampling
When testing for Trihalomethane water
testing from the following sample
points and sample types is required on
a 3 monthly basis:
Water post carbons (or a specific
carbon number depending on unit
design)
a 200ml amber glass container with
ammonium chloride preservative
(pictured).
34
Sampling procedure
is chosen and the sample is taken as
per sampling procedure.
Sampling Procedure for

Trihalomethanes23
To ensure collection of a representative
sample the following technique should
be observed:
1. The ammonium chloride preservative
should be added to the amber glass
bottle (the preservative converts
free chlorine to a combined chlorine
residual ensuring no further byproduct formation occurs before
analysis).
2. When sampling from a tap remove
any aerator and run the tap for 3 to
5 minutes (running allows the water
temperature to stabilise as well as
clearing any stagnant water prior to
THM sample collection).
3. Fill the container to the top. Ensure

no air bubbles pass through the
sample and take care to ensure the
preservative is not flushed out. Do
not rinse the collection container
with the sample water and do not
overfill.
4. Seal the bottle once the sample has
been collected with the white screw
cap ensuring the Teflon liner is in
place.
5. Agitate the bottle by hand for
1 minute to dissolve the preservative.
same as the Pesticides label in different
order.
Label example:
Sample Point:
Post carbon 4
SOLVENT - WASHED
Unique Sample Identification Number: RENTW Preservatives Added: Ammonium Chloride
Preservative Batch Numbers: 1464
Analysis Required: Trihalomethanes
Date Sealed:
10.05.07
By:
R.N. Smith
1464
35

Form example:
(07) 4616 6167

RN Smith
RN
10/05/07
6167

RN Smith
10/05/07
RN
0630 hrs

Do not freeze. Keep out of sunlight.
Do not shake the sample23.
36
Report
Trihalomethane results will be
reported as levels of Trichloromethane
(chloroform), Tribromomethane
(Bromoform), Bromodichloromethane
and Dibromochloromethane (and total
Trihalomethanes) in g/L.
Calcium and Magnesium testing

Calcium and magnesium may also be
present in water at the source. When
calcium and magnesium are present
in the water the water is known as
hard water and once calcium and
magnesium are removed the water is
termed soft. The removal of calcium
and magnesium is often termed as
softening the water.
Calcium and magnesium can coat or
scale the reverse osmosis membrane
decreasing it efficiency. To remove
calcium and magnesium from the water
a water softener is used where calcium
and magnesium ions are exchanged
for sodium ions. The water softener
uses a negatively charged resin (cation
resin) to attract the positively charged
calcium and magnesium ions (cations)
and releases sodium ions during this
exchange14.
Patients may have symptoms of
nausea, vomiting, hypertension,
muscle weakness, headache, malaise,
cardiac symptoms and neurological
disturbances that may lead the clinician
to believe that the patient has dialysed
against hard water5,21,25.
Sampling
When testing for calcium and
magnesium sampling from the
types is required on a 3 monthly basis:
Water post water softener
Calcium and Magnesium levels in
haemodialysis permeate should be less
than 2.0 mg/L5.
a 250ml detergent washed bottle
(pictured). This sample should be kept
out of sunlight in a well sealed bottle.
37
Sampling procedure
is chosen.

same as the Pesticides label.
Label example:
DETERGENT - WASHED
Analysis Required: Total Chlorine and Chloramine level
Date Sealed:
10.05.07
By:
0794

Sample Point:
Feedwater
38
R.N. Smith

Form example:
(07) 4616 6167
RN Smith
RN
10/05/07
6167

RN Smith
10/05/07
RN
0630 hrs

to the testing centre.
No particular instructions are available
for storage or transportation.
Report
Calcium and Magnesium results will be
reported as mg/L.
39
Mercury testing
When testing for mercury sampling
from the following sample points and
sample types is required on an annual
basis:
Water from feed source
Permeate Post RO
Mercury test can also be taken as part
of a standard water test but may be
required at some stage as a separate
sampling procedure. Mercury levels in
haemodialysis permeate should be less
than 0.0002 mg/L2.
Mercury is known to have toxic effects
when ingested orally. The most
significant damage occurs to the
kidneys in the form of tubular necrosis,
proteinuria and hypoalbuminaemia26.
Toxicity when ingested orally has also
resulted in haemorrhagic gastritis and
colitis26.
Mercury is known to be reduced in
water by carbon filtration and reverse
osmosis10.
Container required is a 200ml glass
acid washed with additive 70% nitric
acid and potassium dichromate 50mg/
ml (4mls).
40

Sampling procedure
Fill container half full with water
from testing point and discard.
Fill container again to the top
with water from testing point and
discard.
The third fill will be the sample
collection. Add the nitric acid
preservative (liquid form) and
potassium dichromate then top up
the sample until the container is
full, but not overflowing.
Label example:
NITRIC ACID - WASHED
Unique Sample Identification Number: RENTW Preservatives Added: 70% nitric acid and
potassium dichromate 50mg/ml
Analysis Required: Mercury
Date Sealed:
10.05.07
By:
R.N. Smith
1464

Sample Point:
Post RO

Form example:
(07) 4616 6167

RN Smith
RN
10/05/07
6167

RN Smith
10/05/07
RN
0630 hrs
41

for storage or transportation. Ensure
container is filled without overflowing
Report
Mercury results will be reported as
mg/L.
Heavy Metal testing
Heavy metal test includes levels
of : Silver, Arsenic, Boron, Barium,
Beryllium, Cobalt, Chromium, Copper,
Lead, Cadmium, nickel, chromium,
zinc, iron, manganese, molybdenum,
selenium, vanadium and aluminium.
Lead sampling can also occur
separately if welding or changes to the
piping in the unit occurs.
Sampling
When testing for heavy metals sampling
from the following sample points and
sample types is required on a 3 monthly
basis in rural areas and 6 monthly
otherwise:
Water from feed supply
Permeate post RO
Feed water collection needs: - 250ml
Plastic acid washed container with 70%
nitric acid (2.5ml) additive.
42
Post RO collection needs: 1 litre

detergent washed bottle. No
preservative. Plus the above 250ml
Plastic acid washed container with 70%
nitric acid (2.5ml) additive.

Sampling procedure
Fill container half full with water
from testing point and discard.
Fill container again to the top
with water from testing point and
discard.
The third fill will be the sample

collection. Add the nitric acid
preservative (liquid form) and
then top up the sample until the
container is full, but not overflowing.
Label example:
NITRIC ACID WASHED
Unique Sample Identification Number: RENTW Preservatives Added: 70% nitric acid (2.5ml) additive
Analysis Required: Heavy metals
Date Sealed:
10.05.07
By:
R.N. Smith
1464

Sample Point:
Post RO
43

Form example:
(07) 4616 6167

RN Smith
RN
10/05/07
6167

RN Smith
10/05/07
RN
0630 hrs

44
Report
Heavy metal results will be reported as
levels of Silver, Arsenic, Boron, Barium,
Beryllium, Cobalt, Chromium, Copper,
Lead, Cadmium, nickel, chromium,
zinc, iron, manganese, molybdenum,
selenium, vanadium and aluminium in
mg/L.
Standard Water Testing

A standard water test includes testing
of: Conductivity, pH, Hardness,
Alkalinity, Silica, Total Dissolved
Solids (TDS), Colour, Turbidity and
Cations: - Sodium, Potassium, Calcium,
Magnesium and Hydrogen and Anions:
- Bicarbonate, Carbonate, Hydroxide,
Chloride, Fluoride, Nitrate and Sulphate
plus other Dissolved Elements: - Iron,
Manganese, Zinc, Aluminium, Boron
and Copper.
Lead sampling can also occur
separately if welding or changes to the
piping in the unit occurs.
Sampling
When testing for standard water
sampling from the following sample
points and sample types is required on
a 3 monthly basis:
Water from feed supply
1 litre detergent washed bottle.

No preservative.
Sampling procedure
is chosen.
information as is appropriate. Details
required on this label are the same as
the Pesticides label.
45
Label example:
DETERGENT - WASHED
Analysis Required: Standard water analysis
Date Sealed:
10.05.07
By:
R.N. Smith
1464

Sample Point:
Post RO

Form example:
(07) 4616 6167

RN Smith
RN
10/05/07
6167

46
RN Smith
10/05/07
RN
0630 hrs

Report
Standard water analysis results will
be reported as levels of Conductivity,
pH, Hardness, Alkalinity, Silica,
Total Dissolved Solids (TDS), Colour,
Turbidity, Sodium, Potassium, Calcium,
Magnesium, Hydrogen, Bicarbonate,
Carbonate, Hydroxide, Chloride,
Fluoride, Nitrate, Sulphate, Iron,
Manganese, Zinc, Aluminium, Boron
and Copper.
Machine Testing
Biofilm can adhere inside
haemodialysis machinery and as
such machinery should be correctly
and adequately disinfected. Bacteria
occur naturally in water sources but
can also be introduced or occur due to
reduced water flow. This is significant
in the planning and designing of
haemodialysis units and associated
plumbing as biofilm can adhere
to surfaces such as piping, hoses,
dialysate bottles and inside dialysate
machines15,16.
It is recommended that 30% of all
machines on the haemodialysis floor
should be tested monthly with every
machine being tested at least once
every three months in the in-centre
haemodialysis unit.
It is recommended that in home
machines should be tested three
monthly.
Each individual unit will have specific
guidelines for machine disinfection
including differing methods of
disinfection. Be aware of your own units
guidelines and regime for this. Refer to
Flowchart 1.0.
47
REFERENCES/INFORMATION SOURCES/
SUGGESTED READINGS
1
National Health and Medical Research
Council & Agriculture and Resource
Management Council Of Australia and
New Zealand. 1996, Australian Drinking
Water Guidelines.
2
Association for the Advancement
of Medical Instrumentation. 2001,
American National Standard. Water
Treatment Equipment for Haemodialysis
Applications. ANSI/AAMI.
3
European Pharmacopeia. 2002,
European Guidelines for Haemodialysis.
4
International Organization for
Standardisation. 2006, Draft
International Standard ISO/DIS 23500.
5
Amato, R. 2005, Water Treatment for
Hemodialysis Updated to Include the
Latest AAMI Standards for Dialysate
(RD52:2004). Nephrology Nursing
Journal, Vol. 32, No.2.
6
Luehmann, D., Keshaviah, P., Ward,
R., Klein, E. and Thomas, A. 1989,
A Manual on Water Treatment for
Hemodialysis. U.S. Department of
Health and Human Services.
7
Ahmed, S. 2005, Essentials of
water treatment in hemodialysis.
Hemodialysis International, Vol. 9, pp
127-134.
8
Biomedical/Clinical Engineering
Association of Ireland. Water in
Dialysis. Accessed from http://www.
beai.org/waterindial.html in February,
2007.
48
Brown, J. Kidney Dialysis Facilities and

Plumbing Systems. PM Engineer. Oct
2005, 11, 10.pp 82.
10
Thring, L. Contaminant Removal
Information Sheet. Princess Alexandra
Hospital.
11
Caring for Australians with Renal
Impairment. 2005, Water quality for
Haemodialysis. Accessed at www.cari.
org.au in February, 2007.
12
Ministry of Health Singapore. 2001,
Guidelines for Renal Dialysis Centres.
Accessed from www.moh-ela.gov.sg on
19 April, 2007.
13
Australian Pesticides and Veterinary
Medicines Authority. 2005, Policy on
Limulus Amebocyte Lysate (LAL) Test.
Accessed from
www.apvma.gov.au/guidelines/
limulus_amebocyte_lysate.pdf on 17
April, 2007.
14
Byrne, Wes. 1999, Water Training for
Hemodialysis Volume 1 CD. Company
for Educational Advancement.
15
Curtis, J. and Varughese, P. 2006, Core
Curriculum for the Dialysis Technician:
Module 8 Water Treatment. Amgen
Inc.
16
Charles River. 2001, Bacterial Growth
and Pyrogenic Reactions. LAL
Times. Vol. 8, No. 1.
REFERENCES/INFORMATION SOURCES/
SUGGESTED READINGS
17
Ahmed, S. 2005, Essentials of
water treatment in hemodialysis.
Hemodialysis International, Vol. 9, pp
127-134.
18
Heonich, N. A., and Levin, R. 2003,
The Implications of Water Quality on
Hemodialysis. Seminars in Dialysis, Vol.
16., No.
19
Perez-Gracia, R., & Rodriguez-Benites,
P. Chloramine, a sneaky contaminant
of dialysate. Nephrology Dialysis and
Transplantation, 1999, Vol. 14, pp
2579-2582. Accessed at http://ndt.
oxfordjournals.org/cgi/content/
full/14/11/2579 on 10/07/2005
20
City of Lafayette, 2006. ChloraminesThe City of Lafayette Water Works
Answers Your Questions About
Chloramines. Accessed from www.
lafayette.in.gov/content/global/File/
waterworks/Chloramine_Hand_Out.pdf
in February, 2007.
21
Hoenich, N. A., and Levin, N.W.
Dialysate Purity Standards. Seminars in
Dialysis. 2001, Vol. 14, No.5.
22
Environmental Protection Agency,
2001. Stage 1 Disinfectants and
Disinfection Byproducts Rule: A Quick
Reference Guide. Accessed 27.04.07 at
www.epa.gov/safewater/mdbp/qrg_
st1.pdf
23
Sampling for Trihalomethanes

Information sheet provided by Eva
Comino QHSS 18.04.2007.
24
European Renal Association
European Dialysis and Transplant
Association. Section IV. Dialysis
fluid purity. Nephrology Dialysis and
Transplantation. 2002, Vol. 17, Suppl 7.
25
Thomas, N. 2002, Renal Nursing, 2nd
Edition. Bailliere Tindall, UK.
26
World Health Organisation. 2006,
Guidelines for Drinking-water Quality.
First Addendum to 3rd Edition, Volume
1 Recommendations. World Health
Organisation.
27
Payne, Glenda. A surveyors
Perspective: Water Quality for
Hemodialysis. Hemodialysis Horizons
accessed From www.aami.org in
February, 2007.
28
Mactier, R. and Davies, S. 2006,
Clinical Practice Guidelines for
Haemodialysis. UK Renal Association
Draft 4th Edition. Accessed from http://
www.renal.org/guidelines in February,
2007.
49
50
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STATEWIDE RENAL NETWORK

Statewide Renal Network

Haemodialysis Water Sampling Handbook

The State of Queensland (Queensland Health) 2009.

Statewide Renal Network

Haemodialysis Water Sampling Handbook

Statewide Renal Network

Haemodialysis Water Sampling Handbook

Statewide Renal Network

Haemodialysis Water Sampling Handbook

History of Water Treatment in Dialysis by A/Professor James Petrie

Perhaps the most dramatic example

Statewide Renal Network

Kjellstrand, C.M., Easton, J.W.,

Alfrey, A.C., Mishel, J.M., Burks, J. et

Haemodialysis Water Sampling Handbook

Flendrig, J.A., Jruis, H.G.H. Aluminium

Jochimsen, E.M., Carmichael, W.W.,

Statewide Renal Network

Haemodialysis Water Sampling Handbook

Statewide Renal Network

Water treatment Plant

Haemodialysis Water Sampling Handbook

On return of the water tests (which

Statewide Renal Network

Haemodialysis Water Sampling Handbook

Refer to the manufacturers

materials in haemodialysis water

Table 1. Common disinfectants and piping materials compatibility. Adapted from

Statewide Renal Network

Haemodialysis Water Guidelines

Haemodialysis Water Sampling Handbook

2. Ultrapure water may reduce longterm risk of accelerated vascular

Statewide Renal Network

Haemodialysis Water Sampling Handbook

Table 2. Guideline Comparison.

Statewide Renal Network

Haemodialysis Water Sampling Handbook

Japan Society for

ISO 2006 Draft4

Fungi and Yeast

Table 3. Bacterial and Endotoxin Comparison Table for

After the initial validation of the

Statewide Renal Network

Haemodialysis Water Sampling Handbook

HAEMODIALYSIS UNIT FREQUENCY

Table 4. Haemodialysis Unit Sampling Timetable.

Statewide Renal Network

Haemodialysis Water Sampling Handbook

When using hardness or chlorine

Table 5. In home/community haemodialysis sampling timetable.

Statewide Renal Network

Haemodialysis Water Sampling Handbook

Samples to be collected and tested at

Statewide Renal Network

The test carried out is called the

Haemodialysis Water Sampling Handbook

At least two litres of water should be

Statewide Renal Network

Should a port be used the port will

Haemodialysis Water Sampling Handbook

Step 2. Ensure the label on the

Should the dialysate connector (Hansen

Statewide Renal Network