1) Standards for water quality used in hemodialysis were first developed in the 1970s after certain contaminants in tap water like aluminum and chloramines were found to be toxic to hemodialysis patients.
2) Current standards generally agree on limits for inorganic chemicals but differ on limits for microbiological contaminants like bacteria and endotoxins.
3) Harmonizing standards could improve patient safety by promoting best practices, but requires balancing achievable water quality with constraints of local reimbursement systems.
This document provides information about the Water Quality 2010 conference proceedings. The conference was organized by water@leeds, the water research center at the University of Leeds, and was held on June 23-24, 2010 at the Weetwood Hall Hotel in Leeds, UK. It included keynote speakers, presentations on various topics related to water quality management, policy, research, treatment and monitoring. The proceedings document the program, presentations and posters from the conference.
This document summarizes a study on disinfection byproducts (DBPs) in Canadian provinces and their associated cancer risks and medical expenses. The study investigated occurrences of trihalomethanes (THMs) and haloacetic acids (HAAs) in various Canadian provinces based on water treatment plant data. THM levels were highest in Manitoba, Nova Scotia, and Saskatchewan, while HAA levels were highest in Nova Scotia, Newfoundland and Labrador. Based on DBP exposure levels, the study estimated there may be approximately 700 cancer cases per year in Canada from THM exposure, with associated annual medical expenses of around $140 million, highest in Ontario and Quebec. The paper suggests improvements to reduce DBP formation and associated
Comparative Analysis of Physicochemical Parameters and Heavy Metals of Public...iosrjce
The study examined the physicochemical and heavy metal analysis of municipal water supply along
the distribution channels from source (raw water) to end user points of Kaduna metropolis. Water samples were
collected from the raw water sources of the treatment plants in the metropolis (Malali and Barnawa water
works), treated water from the treatment plant reservoirs, the three booster stations (Kawo, Lugard Hall and
Tudun Wada) and randomly from residential areas which includes; Malali, Barnawa, Tudun Wada, Marafa,
Kabala costain, Badiko, Kurmin Mashi and UnguwanSunusi area of the metropolis. The samples were analyzed
for pH, turbidity, electrical conductivity, total dissolved solids, total hardness, calcium hardness, magnesium
hardness, alkalinity, sulphate, nitrate, DO, BOD, COD, iron and free CO2 using standard procedure described
by American public Health Association(APHA),heavy metals such as chromium, lead, nickel, copper and
cadmium were analyzed using atomic absorption spectroscopy, The result obtained was compared with the
WHO and the Nigerian Standard for Drinking Water set by the Standard Organization of Nigeria(SON). pH and
turbidity of all samples from raw water to treated water delivered to end users with mean values of pH of 5.67
for raw water and a range of 4.48-4.60 for treated water all falls above the permissible limit of 6.5-8.5, turbidity
values of 1883NTU for raw water and a range of 11.60-41.36NTU for treated water all falls above the
permissible limit of 5NTU for portable water other parameters were all within the standard limit, copper and
iron were detected in all samples but within the permissible limit ,lead ,chromium, nickel and cadmium were
above maximum permissible in all samples analyzed
Well Water Groundwater Pennsylvania- Private Well Owners Manual- Our New Educ...Brian Oram
Pennsylvania Groundwater Quality: Your Private Well - A Guide to Drinking Water and Well Water Quality in Pennsylvania. The goal of this booklet is to help educate and inform citizens on issues related to water conservation, ensuring that private water supply systems produce safe drinking water for your family, protecting the long-term quality of our streams and drinking water sources, and helping you to understand the potential sources of pollution to our water resources. The booklet provides general information explaining certified water testing, chain-of-custody, and drinking water regulations and standards. It provides information related to the health (primary standards) or aesthetic (secondary standards) concerns for each parameter and provides information on water quality parameters that do not specifically have a drinking water limit. This reference is intended as a guide to understand water quality by providing guidance on selecting water quality testing parameters for baseline testing from a citizen's perspective and by serving as a tool to help interpret water quality data. In some cases, this document provides guidance on what actions you may want to consider.
Comments about the New Booklet (unsolicited)
Source: PA State Representative - " Your Guide very helpfully for me and my constituents who own private wells... and is an instructive guide to me as a policy maker as I strive to protect our water supply" (October 31, 2012).
For Slatington, PA - Yes- We received , thank you very much. The information is great! (December 2012).
WOW ! that was fast !! our son has moved in to his house at Harvey's Lake, read the book, and we both learned a lot (December 2012).
Happy new year! I received your package in the mail today. You have really developed a wonderful educational guide. I read the consent form as well and your idea is something I would really like to get behind. (January 2013)
This study analyzed nutrient and bacterial concentrations in Bowne Park Pond over time. Algal blooms were previously observed, indicating potential eutrophication. Water samples were tested for nutrients and bacteria using various methods. Results showed high nutrient levels, likely due to surface runoff during heavy rainfall. Total coliform levels increased from 18 to 24 hours of incubation. Enterococcus levels remained relatively constant, suggesting it may be a more stable indicator of contamination than E. coli or total coliform. Future studies are needed to determine if the pond is prone to eutrophication, and if remedial actions are required to protect the marine habitat and public.
Sulphate and Hardness_Elphick et al_ET&CGuy Gilron
This document presents the results of a study evaluating the chronic toxicity of sulfate in various aquatic organisms. A variety of test species, including invertebrates, fish, algae, moss, and an amphibian, were exposed to sulfate under different water hardness conditions. The results show that sulfate toxicity decreases with increasing water hardness. Based on these findings, the authors calculated water quality guidelines for sulfate separately for soft, moderately hard, and hard water. The guidelines ranged from 75 to 725 mg/L sulfate depending on the water hardness and calculation method. The study provides a robust dataset that can be used to establish scientifically defensible sulfate guidelines that account for the modifying effect of water hardness.
This document provides information about the Water Quality 2010 conference proceedings. The conference was organized by water@leeds, the water research center at the University of Leeds, and was held on June 23-24, 2010 at the Weetwood Hall Hotel in Leeds, UK. It included keynote speakers, presentations on various topics related to water quality management, policy, research, treatment and monitoring. The proceedings document the program, presentations and posters from the conference.
This document summarizes a study on disinfection byproducts (DBPs) in Canadian provinces and their associated cancer risks and medical expenses. The study investigated occurrences of trihalomethanes (THMs) and haloacetic acids (HAAs) in various Canadian provinces based on water treatment plant data. THM levels were highest in Manitoba, Nova Scotia, and Saskatchewan, while HAA levels were highest in Nova Scotia, Newfoundland and Labrador. Based on DBP exposure levels, the study estimated there may be approximately 700 cancer cases per year in Canada from THM exposure, with associated annual medical expenses of around $140 million, highest in Ontario and Quebec. The paper suggests improvements to reduce DBP formation and associated
Comparative Analysis of Physicochemical Parameters and Heavy Metals of Public...iosrjce
The study examined the physicochemical and heavy metal analysis of municipal water supply along
the distribution channels from source (raw water) to end user points of Kaduna metropolis. Water samples were
collected from the raw water sources of the treatment plants in the metropolis (Malali and Barnawa water
works), treated water from the treatment plant reservoirs, the three booster stations (Kawo, Lugard Hall and
Tudun Wada) and randomly from residential areas which includes; Malali, Barnawa, Tudun Wada, Marafa,
Kabala costain, Badiko, Kurmin Mashi and UnguwanSunusi area of the metropolis. The samples were analyzed
for pH, turbidity, electrical conductivity, total dissolved solids, total hardness, calcium hardness, magnesium
hardness, alkalinity, sulphate, nitrate, DO, BOD, COD, iron and free CO2 using standard procedure described
by American public Health Association(APHA),heavy metals such as chromium, lead, nickel, copper and
cadmium were analyzed using atomic absorption spectroscopy, The result obtained was compared with the
WHO and the Nigerian Standard for Drinking Water set by the Standard Organization of Nigeria(SON). pH and
turbidity of all samples from raw water to treated water delivered to end users with mean values of pH of 5.67
for raw water and a range of 4.48-4.60 for treated water all falls above the permissible limit of 6.5-8.5, turbidity
values of 1883NTU for raw water and a range of 11.60-41.36NTU for treated water all falls above the
permissible limit of 5NTU for portable water other parameters were all within the standard limit, copper and
iron were detected in all samples but within the permissible limit ,lead ,chromium, nickel and cadmium were
above maximum permissible in all samples analyzed
Well Water Groundwater Pennsylvania- Private Well Owners Manual- Our New Educ...Brian Oram
Pennsylvania Groundwater Quality: Your Private Well - A Guide to Drinking Water and Well Water Quality in Pennsylvania. The goal of this booklet is to help educate and inform citizens on issues related to water conservation, ensuring that private water supply systems produce safe drinking water for your family, protecting the long-term quality of our streams and drinking water sources, and helping you to understand the potential sources of pollution to our water resources. The booklet provides general information explaining certified water testing, chain-of-custody, and drinking water regulations and standards. It provides information related to the health (primary standards) or aesthetic (secondary standards) concerns for each parameter and provides information on water quality parameters that do not specifically have a drinking water limit. This reference is intended as a guide to understand water quality by providing guidance on selecting water quality testing parameters for baseline testing from a citizen's perspective and by serving as a tool to help interpret water quality data. In some cases, this document provides guidance on what actions you may want to consider.
Comments about the New Booklet (unsolicited)
Source: PA State Representative - " Your Guide very helpfully for me and my constituents who own private wells... and is an instructive guide to me as a policy maker as I strive to protect our water supply" (October 31, 2012).
For Slatington, PA - Yes- We received , thank you very much. The information is great! (December 2012).
WOW ! that was fast !! our son has moved in to his house at Harvey's Lake, read the book, and we both learned a lot (December 2012).
Happy new year! I received your package in the mail today. You have really developed a wonderful educational guide. I read the consent form as well and your idea is something I would really like to get behind. (January 2013)
This study analyzed nutrient and bacterial concentrations in Bowne Park Pond over time. Algal blooms were previously observed, indicating potential eutrophication. Water samples were tested for nutrients and bacteria using various methods. Results showed high nutrient levels, likely due to surface runoff during heavy rainfall. Total coliform levels increased from 18 to 24 hours of incubation. Enterococcus levels remained relatively constant, suggesting it may be a more stable indicator of contamination than E. coli or total coliform. Future studies are needed to determine if the pond is prone to eutrophication, and if remedial actions are required to protect the marine habitat and public.
Sulphate and Hardness_Elphick et al_ET&CGuy Gilron
This document presents the results of a study evaluating the chronic toxicity of sulfate in various aquatic organisms. A variety of test species, including invertebrates, fish, algae, moss, and an amphibian, were exposed to sulfate under different water hardness conditions. The results show that sulfate toxicity decreases with increasing water hardness. Based on these findings, the authors calculated water quality guidelines for sulfate separately for soft, moderately hard, and hard water. The guidelines ranged from 75 to 725 mg/L sulfate depending on the water hardness and calculation method. The study provides a robust dataset that can be used to establish scientifically defensible sulfate guidelines that account for the modifying effect of water hardness.
Environmental Risks from bulk chlorine rev 4 3 16Nigel Harrison
This document summarizes an environmental risk assessment of potential chlorine releases from bulk storage installations at three Anglian Water treatment works. Six potential unmitigated accident scenarios were modeled and assessed as "Sub-MATTE", meaning they would not be considered major accidents to the environment. The assessment identified potential pathways between chlorine sources and environmental receptors. It determined severity levels and duration/recovery categories for receptors based on modeling and established tolerability thresholds. The document provides context on Anglian Water's COMAH regulations requirements and the chlorination systems. It outlines the accident scenarios modeled, including leak sizes and frequencies.
This document discusses compounds of emerging concern (CECs) in water and their impact on water utilities. While more research is needed, CECs like pharmaceuticals are ubiquitous in wastewater discharges and detected in surface waters downstream. These compounds can disrupt human and aquatic endocrine systems even at very low concentrations. There is evidence that CECs negatively impact aquatic organisms, with some fish found downstream of wastewater discharges exhibiting intersex characteristics. As detection methods improve, CECs are an increasing regulatory concern that will shape future water and wastewater treatment processes.
The Peace River Manasota Regional Water Supply Authority provides wholesale potable water to local governments and communities in southwest Florida. The Authority and its customers experience variations in raw water quality from different sources that impact the quality of the finished water entering their distribution systems. A study was conducted to characterize the regional water quality to help manage the system and ensure continued delivery of high quality water.
The SAJO Consulting Group was commissioned by Quintin Rochfort of Environment Canada to investigate contaminants in the Rouge River stormwater pond and evaluate its environmental condition. They collected water, sediment, and pore water samples from 4 sites in the pond during fall and spring seasons. Analysis found high concentrations of pollutants like road salts, cyanide, PAHs and phosphorus throughout the pond, especially at site 4. Based on the poor water and sediment quality, high contaminant levels, and unsuitable conditions for aquatic life, the overall pond condition was deemed poor. The report recommended draining the pond and excavating/disposing of contaminated sediment, especially from site 4, to improve conditions.
This document summarizes the results of a study analyzing the physicochemical and bacteriological properties of sachet water samples from four depots in Kano, Nigeria. The samples were tested for pH, turbidity, conductivity, total solids, alkalinity, hardness, bacteria, heavy metals, and anions. Most parameters were within WHO guidelines, indicating the water was generally safe for consumption. While some samples contained low levels of metals like copper, zinc, and iron, concentrations did not exceed permitted limits. No bacteria or E. coli were detected, showing an absence of fecal contamination. In conclusion, the sachet water quality was found to meet recommended standards for potable water.
The document discusses membrane bioreactor (MBR) systems for wastewater treatment. It provides common ranges for key design parameters like membrane flux rates, mixed liquor suspended solids concentrations, and aeration requirements. The text indicates MBR systems require careful design to prevent fouling and ensure integrity. It also notes TCEQ may require a pilot study or 2-year performance bond for non-standard MBR proposals.
THE EFFECT OF WATER TREATMENT ON CALCIUM AND BERYLLIUM LEVELS OF WATER IN KAR...EDITOR IJCRCPS
Introduction: Water quality is an important issue for human health management.The aim of this research was to compare calcium
and beryllium levels in the water of Karun river at the influent stream of the water treatment plant number two (WTP2) in Ahvaz city
and Byblus and Anahita companies and their outlet water after the water treatment process. Materials and Methods: Fourteen
samples of Karun river water at the inlet of AhvazWTP2and Byblus and Anahita companies and their outlet water after the water
treatment process were collected during five months (September2013, and January - April 2014). Samples were taken fourteen
times, each time; five, one liter samples were collected. The samples were then mix and one liter composite sample was isolated
and transported to laboratory. The collected samples were filtered through filter paper (0.45 μm). For their fixation and pro tection
by nitric acid the pH adjusted ≤2 and was analyzed by ICP-MS. Results: it was shown that average of Calcium in water at the inlet
of AhvazWTP2and Byblus and Anahita companies and their outlet water after the water treatment process were 164.714, 94.571,
111.714, 54.485, 124.571, and 17.528 μg/l ,respectively. Also, average of Beryllium in water at the inlet of AhvazWTP2and Byblus
and Anahita companies and their outlet water after the water treatment process were 15.142, 5.714, 8.714, 2.571, 9.428 and 2.285
μg/l, respectively. Conclusion: The results showed that the purification process causes reduction in content of metals in waters
Keywords: Karun River, beryllium, calcium, water treatment process, ICP-MS.
Risks and Assessments of Cyanotoxins in Drinking WaterRuben Diaz
The document discusses the risks posed by cyanotoxins, which are toxins produced by cyanobacteria, in drinking water. Cyanotoxins have been found in drinking water supplies around the world and can cause health issues if ingested, such as gastrointestinal, neurological, and liver damage. Water treatment plants are working to implement assessment methods and treatments like coagulation, oxidation, activated carbon, and advanced filtration to remove cyanotoxins from drinking water with varying levels of success. Scientists and environmentalists are focused on developing efficient treatment methods and informing the public about the risks of cyanotoxins.
Kenya; The Long Term Sustainability Of Household Bio-Sand FiltrationV9X
The document summarizes an evaluation of bio-sand water filters introduced 4 years prior in rural Kenya. Key findings include:
1) Of the 51 filters tested, 70.6% were producing water with acceptable coliform levels, showing the filters were still effective after 4 years of use.
2) Poor maintenance habits, such as infrequent cleaning, were found to contribute to lower water quality from some filters.
3) The study identified risks like infrequent cleaning, child/animal access, and contaminated raw water as increasing the chances of unacceptable water from the filters. Promoting proper maintenance could improve water quality.
4) While most filters were still functioning well after 4 years, some produced slower flow
The International Journal of Engineering and Science (IJES)theijes
The International Journal of Engineering & Science is aimed at providing a platform for researchers, engineers, scientists, or educators to publish their original research results, to exchange new ideas, to disseminate information in innovative designs, engineering experiences and technological skills. It is also the Journal's objective to promote engineering and technology education. All papers submitted to the Journal will be blind peer-reviewed. Only original articles will be published.
Dr J N Brown - PhD thesis (2002) Partitioning of Chemical Contaminants in Urb...Jeff Brown, PhD, CNMA
This thesis examines the partitioning of polycyclic aromatic hydrocarbons (PAHs) between particulate, colloidal, and truly dissolved phases in urban stormwater. Stormwater samples were collected from an urban and rural catchment during rainfall events and analyzed for PAHs and heavy metals. The PAHs in urban stormwater were primarily from combustion sources on streets. A new method was developed to separate the colloidal and truly dissolved phases using solid phase extraction disks. This study provides insights into the transport, fate and environmental effects of PAHs in urban stormwater discharged into harbors.
This document reports on a treatment wetland project that evaluated the effects of different macrophyte species and anammox seeding sources in constructed wetlands. Four wetland mesocosms were operated for 7 weeks, including two vegetated submerged bed wetlands planted with different species and two free water surface wetlands seeded with different sources. Water quality parameters were measured weekly and samples were analyzed for nitrogen species, microorganisms, and fecal coliform. The results showed differences in nitrogen removal performance between the wetland types, with the vegetated submerged bed wetlands generally achieving higher ammonium removal rates than the free water surface wetlands. Microbial analysis identified various bacteria and protozoa present that contribute to nitrogen
- Emerging pathogens in wastewater effluent pose new public health risks as they are more resistant to treatment and infection from low doses is possible. Meeting regulatory standards may not sufficiently address risks from emerging pathogens.
- Wastewater treatment plants can discharge emerging pathogens in concentrations that exceed drinking water standards and increase health risks for downstream drinking water intakes. Additional treatment such as ultraviolet disinfection and membrane filtration can further reduce emerging pathogen levels.
- A collaborative approach between water, wastewater, and public health groups is needed to develop risk-based standards and strategies that mitigate emerging pathogen contamination of receiving waters and better protect public health.
Water Quality Assessment through GIS: A Case Study of Sukhna Lake, Chandigarh...IRJET Journal
This document summarizes a study assessing the water quality of Sukhna Lake in Chandigarh, India through GIS analysis. Water samples were collected from eight locations around the lake and tested for various physicochemical and bacteriological parameters, including pH, temperature, turbidity, dissolved oxygen, and E. coli. The results found that most parameter levels were within national standards for freshwater lakes, except for higher readings of biochemical oxygen demand, chemical oxygen demand, and turbidity at some sites, indicating moderate pollution. GIS maps were created to visualize the spatial variation of parameters like biochemical oxygen demand, chemical oxygen demand, and dissolved oxygen across the lake. The study aims to evaluate the current water quality conditions and identify pollution hot
The City of Dania Beach routinely monitors its drinking water supply and submits reports on water quality. Testing in 2012 found the water safe within regulatory limits, except the City failed to complete all required lead and copper sampling between July and December. The water source is underground aquifers accessed by wells 65 feet deep. Water is treated through lime softening, filtration, disinfection and fluoride addition. About 17,000 customers receive water meeting health standards, though some groups may be at higher risk and should take precautions.
The 2013 annual drinking water quality report from the City of Dania Beach provides information on the source and quality of the city's drinking water. Key points include:
- The city's water source is wells drawing from the Biscayne Aquifer at a depth of 65 feet.
- Testing found no potential sources of contamination near the wells.
- Treatment includes lime softening, filtration, disinfection with chlorine, and fluoride addition.
- Monitoring detected no contaminants in excess of allowed levels with the exceptions of occasional positive tests for total coliform and E. coli bacteria, which were addressed through corrective actions and additional sampling.
- An average hemodialysis patient is exposed to 560 liters of water through weekly treatments, more than most people use in a lifetime. Proper water treatment is important to remove impurities and minerals that can be toxic to patients or damage equipment.
- Water is treated through pre-treatment including filtration, softening, and carbon adsorption. Primary purification uses reverse osmosis or deionization to remove 95% of contaminants. Purified water is then distributed through disinfected piping to avoid microbiological contamination.
- Standards are in place to ensure safe water purification for dialysis and protect patients from issues like anemia, bone disease, or infection.
This document discusses various quality metrics and targets in hemodialysis. It begins by covering dietary compliance metrics like inter-dialytic weight gain and serum levels of potassium, phosphate, and BUN. It then discusses the effects of rapid ultrafiltration and links various metrics like inter-dialytic weight gain and blood pressure to outcomes. The rest of the document outlines targets for hemoglobin, calcium and phosphate levels, lipids, uric acid, ferritin, and other markers based on studies showing associations with mortality rates.
Environmental Risks from bulk chlorine rev 4 3 16Nigel Harrison
This document summarizes an environmental risk assessment of potential chlorine releases from bulk storage installations at three Anglian Water treatment works. Six potential unmitigated accident scenarios were modeled and assessed as "Sub-MATTE", meaning they would not be considered major accidents to the environment. The assessment identified potential pathways between chlorine sources and environmental receptors. It determined severity levels and duration/recovery categories for receptors based on modeling and established tolerability thresholds. The document provides context on Anglian Water's COMAH regulations requirements and the chlorination systems. It outlines the accident scenarios modeled, including leak sizes and frequencies.
This document discusses compounds of emerging concern (CECs) in water and their impact on water utilities. While more research is needed, CECs like pharmaceuticals are ubiquitous in wastewater discharges and detected in surface waters downstream. These compounds can disrupt human and aquatic endocrine systems even at very low concentrations. There is evidence that CECs negatively impact aquatic organisms, with some fish found downstream of wastewater discharges exhibiting intersex characteristics. As detection methods improve, CECs are an increasing regulatory concern that will shape future water and wastewater treatment processes.
The Peace River Manasota Regional Water Supply Authority provides wholesale potable water to local governments and communities in southwest Florida. The Authority and its customers experience variations in raw water quality from different sources that impact the quality of the finished water entering their distribution systems. A study was conducted to characterize the regional water quality to help manage the system and ensure continued delivery of high quality water.
The SAJO Consulting Group was commissioned by Quintin Rochfort of Environment Canada to investigate contaminants in the Rouge River stormwater pond and evaluate its environmental condition. They collected water, sediment, and pore water samples from 4 sites in the pond during fall and spring seasons. Analysis found high concentrations of pollutants like road salts, cyanide, PAHs and phosphorus throughout the pond, especially at site 4. Based on the poor water and sediment quality, high contaminant levels, and unsuitable conditions for aquatic life, the overall pond condition was deemed poor. The report recommended draining the pond and excavating/disposing of contaminated sediment, especially from site 4, to improve conditions.
This document summarizes the results of a study analyzing the physicochemical and bacteriological properties of sachet water samples from four depots in Kano, Nigeria. The samples were tested for pH, turbidity, conductivity, total solids, alkalinity, hardness, bacteria, heavy metals, and anions. Most parameters were within WHO guidelines, indicating the water was generally safe for consumption. While some samples contained low levels of metals like copper, zinc, and iron, concentrations did not exceed permitted limits. No bacteria or E. coli were detected, showing an absence of fecal contamination. In conclusion, the sachet water quality was found to meet recommended standards for potable water.
The document discusses membrane bioreactor (MBR) systems for wastewater treatment. It provides common ranges for key design parameters like membrane flux rates, mixed liquor suspended solids concentrations, and aeration requirements. The text indicates MBR systems require careful design to prevent fouling and ensure integrity. It also notes TCEQ may require a pilot study or 2-year performance bond for non-standard MBR proposals.
THE EFFECT OF WATER TREATMENT ON CALCIUM AND BERYLLIUM LEVELS OF WATER IN KAR...EDITOR IJCRCPS
Introduction: Water quality is an important issue for human health management.The aim of this research was to compare calcium
and beryllium levels in the water of Karun river at the influent stream of the water treatment plant number two (WTP2) in Ahvaz city
and Byblus and Anahita companies and their outlet water after the water treatment process. Materials and Methods: Fourteen
samples of Karun river water at the inlet of AhvazWTP2and Byblus and Anahita companies and their outlet water after the water
treatment process were collected during five months (September2013, and January - April 2014). Samples were taken fourteen
times, each time; five, one liter samples were collected. The samples were then mix and one liter composite sample was isolated
and transported to laboratory. The collected samples were filtered through filter paper (0.45 μm). For their fixation and pro tection
by nitric acid the pH adjusted ≤2 and was analyzed by ICP-MS. Results: it was shown that average of Calcium in water at the inlet
of AhvazWTP2and Byblus and Anahita companies and their outlet water after the water treatment process were 164.714, 94.571,
111.714, 54.485, 124.571, and 17.528 μg/l ,respectively. Also, average of Beryllium in water at the inlet of AhvazWTP2and Byblus
and Anahita companies and their outlet water after the water treatment process were 15.142, 5.714, 8.714, 2.571, 9.428 and 2.285
μg/l, respectively. Conclusion: The results showed that the purification process causes reduction in content of metals in waters
Keywords: Karun River, beryllium, calcium, water treatment process, ICP-MS.
Risks and Assessments of Cyanotoxins in Drinking WaterRuben Diaz
The document discusses the risks posed by cyanotoxins, which are toxins produced by cyanobacteria, in drinking water. Cyanotoxins have been found in drinking water supplies around the world and can cause health issues if ingested, such as gastrointestinal, neurological, and liver damage. Water treatment plants are working to implement assessment methods and treatments like coagulation, oxidation, activated carbon, and advanced filtration to remove cyanotoxins from drinking water with varying levels of success. Scientists and environmentalists are focused on developing efficient treatment methods and informing the public about the risks of cyanotoxins.
Kenya; The Long Term Sustainability Of Household Bio-Sand FiltrationV9X
The document summarizes an evaluation of bio-sand water filters introduced 4 years prior in rural Kenya. Key findings include:
1) Of the 51 filters tested, 70.6% were producing water with acceptable coliform levels, showing the filters were still effective after 4 years of use.
2) Poor maintenance habits, such as infrequent cleaning, were found to contribute to lower water quality from some filters.
3) The study identified risks like infrequent cleaning, child/animal access, and contaminated raw water as increasing the chances of unacceptable water from the filters. Promoting proper maintenance could improve water quality.
4) While most filters were still functioning well after 4 years, some produced slower flow
The International Journal of Engineering and Science (IJES)theijes
The International Journal of Engineering & Science is aimed at providing a platform for researchers, engineers, scientists, or educators to publish their original research results, to exchange new ideas, to disseminate information in innovative designs, engineering experiences and technological skills. It is also the Journal's objective to promote engineering and technology education. All papers submitted to the Journal will be blind peer-reviewed. Only original articles will be published.
Dr J N Brown - PhD thesis (2002) Partitioning of Chemical Contaminants in Urb...Jeff Brown, PhD, CNMA
This thesis examines the partitioning of polycyclic aromatic hydrocarbons (PAHs) between particulate, colloidal, and truly dissolved phases in urban stormwater. Stormwater samples were collected from an urban and rural catchment during rainfall events and analyzed for PAHs and heavy metals. The PAHs in urban stormwater were primarily from combustion sources on streets. A new method was developed to separate the colloidal and truly dissolved phases using solid phase extraction disks. This study provides insights into the transport, fate and environmental effects of PAHs in urban stormwater discharged into harbors.
This document reports on a treatment wetland project that evaluated the effects of different macrophyte species and anammox seeding sources in constructed wetlands. Four wetland mesocosms were operated for 7 weeks, including two vegetated submerged bed wetlands planted with different species and two free water surface wetlands seeded with different sources. Water quality parameters were measured weekly and samples were analyzed for nitrogen species, microorganisms, and fecal coliform. The results showed differences in nitrogen removal performance between the wetland types, with the vegetated submerged bed wetlands generally achieving higher ammonium removal rates than the free water surface wetlands. Microbial analysis identified various bacteria and protozoa present that contribute to nitrogen
- Emerging pathogens in wastewater effluent pose new public health risks as they are more resistant to treatment and infection from low doses is possible. Meeting regulatory standards may not sufficiently address risks from emerging pathogens.
- Wastewater treatment plants can discharge emerging pathogens in concentrations that exceed drinking water standards and increase health risks for downstream drinking water intakes. Additional treatment such as ultraviolet disinfection and membrane filtration can further reduce emerging pathogen levels.
- A collaborative approach between water, wastewater, and public health groups is needed to develop risk-based standards and strategies that mitigate emerging pathogen contamination of receiving waters and better protect public health.
Water Quality Assessment through GIS: A Case Study of Sukhna Lake, Chandigarh...IRJET Journal
This document summarizes a study assessing the water quality of Sukhna Lake in Chandigarh, India through GIS analysis. Water samples were collected from eight locations around the lake and tested for various physicochemical and bacteriological parameters, including pH, temperature, turbidity, dissolved oxygen, and E. coli. The results found that most parameter levels were within national standards for freshwater lakes, except for higher readings of biochemical oxygen demand, chemical oxygen demand, and turbidity at some sites, indicating moderate pollution. GIS maps were created to visualize the spatial variation of parameters like biochemical oxygen demand, chemical oxygen demand, and dissolved oxygen across the lake. The study aims to evaluate the current water quality conditions and identify pollution hot
The City of Dania Beach routinely monitors its drinking water supply and submits reports on water quality. Testing in 2012 found the water safe within regulatory limits, except the City failed to complete all required lead and copper sampling between July and December. The water source is underground aquifers accessed by wells 65 feet deep. Water is treated through lime softening, filtration, disinfection and fluoride addition. About 17,000 customers receive water meeting health standards, though some groups may be at higher risk and should take precautions.
The 2013 annual drinking water quality report from the City of Dania Beach provides information on the source and quality of the city's drinking water. Key points include:
- The city's water source is wells drawing from the Biscayne Aquifer at a depth of 65 feet.
- Testing found no potential sources of contamination near the wells.
- Treatment includes lime softening, filtration, disinfection with chlorine, and fluoride addition.
- Monitoring detected no contaminants in excess of allowed levels with the exceptions of occasional positive tests for total coliform and E. coli bacteria, which were addressed through corrective actions and additional sampling.
- An average hemodialysis patient is exposed to 560 liters of water through weekly treatments, more than most people use in a lifetime. Proper water treatment is important to remove impurities and minerals that can be toxic to patients or damage equipment.
- Water is treated through pre-treatment including filtration, softening, and carbon adsorption. Primary purification uses reverse osmosis or deionization to remove 95% of contaminants. Purified water is then distributed through disinfected piping to avoid microbiological contamination.
- Standards are in place to ensure safe water purification for dialysis and protect patients from issues like anemia, bone disease, or infection.
This document discusses various quality metrics and targets in hemodialysis. It begins by covering dietary compliance metrics like inter-dialytic weight gain and serum levels of potassium, phosphate, and BUN. It then discusses the effects of rapid ultrafiltration and links various metrics like inter-dialytic weight gain and blood pressure to outcomes. The rest of the document outlines targets for hemoglobin, calcium and phosphate levels, lipids, uric acid, ferritin, and other markers based on studies showing associations with mortality rates.
Bacteriological analysis of drinking water by MPN method.prakashtu
This document describes the MPN (Most Probable Number) method for analyzing drinking water bacteriologically. The MPN method involves inoculating water samples in multiple dilutions into lactose broths to detect coliform bacteria presence. Positive samples are then cultured on EMB agar to isolate and identify E. coli. Confirmed E. coli colonies produce acid and gas when cultured in lactose broth at 44.5°C. The number of positive samples at each dilution level is used with statistical tables to estimate the MPN of coliform bacteria per 100ml of water. This provides a statistical analysis of bacteria levels in drinking water samples.
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Calidad del agua para agricultura fao 29-ayers y westcot 1985-okiPIEDRON
This document provides guidelines for evaluating water quality for agricultural irrigation. It discusses four main water quality problems: salinity, infiltration rate, toxicity, and miscellaneous other issues. For each problem, the document describes guidelines for interpreting water quality data, potential impacts on crops, and management options. It provides water quality guidelines in tables and discusses experiences using various water qualities from different locations worldwide.
1. Water treatment for hemodialysis is crucial but often neglected. Contaminants in water can cause significant acute and long-term harm to patients if not properly treated.
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This document summarizes the global issue of arsenic contamination of groundwater sources and the health risks posed by consumption of arsenic-contaminated drinking water. It notes that millions of people across multiple countries in Asia and Latin America have been exposed to high levels of arsenic in drinking water. Common health effects include various cancers and skin lesions that develop over long periods of exposure. The document reviews mitigation strategies including using alternative uncontaminated water sources, deeper wells, and arsenic removal technologies like ion exchange, filtration, and activated alumina that have been applied at the community level. Effective and sustainable solutions require addressing social and behavioral factors through communication programs.
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Water quality can be assessed through various physical, chemical, and biological indicators. It depends on factors like geology, ecosystem, and human activities. Standards are set based on intended uses like drinking, industrial, or environmental. Water is sampled and tested using on-site or laboratory methods to monitor these indicators. Maintaining adequate water quality is important for public health and ecosystem protection.
Long Island relies solely on groundwater for drinking water. Contamination from improper disposal of household hazardous waste and excess nutrients like nitrogen are negatively impacting water quality. Nitrogen levels are rising in all aquifers due to septic systems, sewage treatment plants, fertilizers, and agriculture. Common contaminants detected include volatile organic chemicals, MTBE, and pesticides. Over 100 pesticides have been found in drinking water wells. The top three pesticides detected are imidacloprid, atrazine, and metalaxyl. Pharmaceutical drugs are also emerging contaminants being detected in surface and groundwater. Proper disposal of wastes and reduction of hazardous chemicals is needed to protect Long Island's sole source aqu
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This document discusses the selenium drinking water quality guideline (DWQG) in Canada and argues that the current guideline of 10 μg/L is overly protective and not scientifically justified. Most jurisdictions worldwide use 10 μg/L as the guideline, except for the United States and South Africa which use 50 μg/L. The Canadian guideline is based on outdated assumptions from 1992 that selenium is carcinogenic, but recent evidence shows it is not and may have anticarcinogenic properties. The document argues Canada and other countries should re-evaluate and revise their generic DWQGs in light of new scientific data, and consider developing site-specific, risk-based objectives in the interim.
The Effects of Pipe Material and Age on the Formation of Disinfection By – Pr...Marwan Haddad
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water, a substance composed of the chemical elements hydrogen and oxygen and existing in gaseous, liquid, and solid states. It is one of the most plentiful and essential of compounds. A tasteless and odourless liquid at room temperature, it has the important ability to dissolve many other substances.
This document discusses various topics related to drinking water quality including:
1. Definitions of key terms like quality, potable water, and contaminated water.
2. Global water quantities and scarcity issues facing many regions of the world.
3. Water resources and consumption patterns in Pakistan, highlighting declining per capita availability and future shortages.
4. Common impurities found in drinking water and associated health impacts like bacteria, salts, heavy metals, and radiation.
5. Important water quality parameters including physical, chemical, biological, and radiological measures used to evaluate water safety.
This document summarizes a study on microcystin levels in raw and treated municipal drinking water sources in Alberta. Microcystin is a toxin produced by some cyanobacteria (blue-green algae) that can be harmful to human health. The study analyzed water samples from 18 municipalities over 10 weeks and found microcystin present in 67% of raw water samples, with concentrations up to 14.8 μg/L in some sources. Microcystin was detected less often and at lower levels in treated water, indicating conventional treatment removes some toxin. All samples complied with Health Canada guidelines. The study recommends further sampling of rural communities to fully evaluate microcystin occurrence in municipal surface drinking water supplies.
Recycled Water: Wastewater Poised to Be a Significant Source of The Nation's ...larrycotcher
A report from the National Research Council suggests that treated wastewater has the potential to be a large part of the future US water supply, though using wastewater is controversial. While water recycling is already practiced in the US for less than 1% of water, increasing reuse could provide 27% of public supply by treating the 12 billion gallons of wastewater discharged daily. The report found that treated wastewater does not pose health risks and that recycling costs vary but can be less than desalination while complementing other water sources and strategies.
The Impact of Ozone as a Secondary Disinfection SystemDEL Ozone
This document discusses secondary disinfection systems for public swimming venues, specifically focusing on ozone and UV systems. It notes that the upcoming Model Aquatic Health Code (MAHC) will require secondary disinfection for venues like therapy pools and those designed for young children, to significantly reduce recreational water illnesses. Ozone and UV are approved secondary disinfection technologies that can provide a minimum 3-log reduction of Cryptosporidium. The document then provides details on ozone, its benefits over chlorine, how it is measured, and that it is most effective when used alongside a small chlorine residual.
This document discusses specifications for drinking water set by the Bureau of Indian Standards (BIS) and the World Health Organization (WHO). It outlines the importance of setting standards to protect public health and compares BIS and WHO standards. Key parameters tested by both organizations include physical, chemical, bacteriological, and biological contaminants. Standards are meant to characterize safe levels of substances and vary between countries based on needs and conditions. The WHO and BIS both use a multi-stage process involving risk assessment and public input to determine acceptable risk levels and set standards accordingly.
A field experiment was conducted to determine the impact of low pH on the survival and settlement of dreissenid mussels. Water from Lake Ontario containing mussel larvae was pumped to a laboratory and divided into streams, with three streams having their pH adjusted to 7.3, 7.1, and 6.9 using phosphoric acid. The fourth stream served as a control. Adult mussels and settlement substrates were placed in tanks receiving each pH level or the control water. After 10 weeks, adult mortality reached 40% at pH 6.9. Adult mussels were significantly lighter at all pH levels compared to controls, indicating shell erosion and calcium loss. New settlement was essentially prevented at pH 7.1. The results suggest lowering pH
Physicochemical and Bacteriological Analyses of Sachets Water Samples in Kano...IOSR Journals
Physicochemical and bacteriological analyses of sachets water samples in Kano metropolis were
carried out using standard procedures to assess the quality of such water consumed in the area. Samples were
collected from four different water depots in different parts of Kano metropolis. The results showed variations in
the concentrations of the analyzed parameters in the water samples. The pH values ranged from 6.97±0.20 to
7.25±0.33; Electrical Conductivity ranged from 176 ±0.02 to 282±0.25μS/cm; Alkalinity ranged from 0.17±0.02
to 0.69±0.28 mg/l; Total solids were in the range of 100.30±0.25 to 157.34±0.30mg/l. Total Dissolved Solids
ranged from 67.80±0.30 to 84.70±0.23mg/l; Total Suspended Solids ranged from 15.60±0.36 to75.84±0.02mg/;
Total Hardness ranged from 85.00±0.03 to 103.00±0.20 mg/ and turbidity ranged from 0.60±0.21 to 2.23±0.32
NTU. Escherichia coli (E.coli) were not detected in all the samples. The levels of some of the anions analyzed
ranged from 0.03±0.00 mg/l NO2
- to 7.06 ±0.02 mg/l SO4
2-. Similarly, the levels of some of the heavy metals
analyzed ranged from 0.12±0.02mg/l Cu to 0.71±0.01mg/l Fe. Accordingly, the water samples were colourless
and odourless. In general, the concentrations of all the parameters analyzed in the samples were below or
within the World Health Organization (WHO) permissible limits, indicating that the sachets water were safe for
human consumption.
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1 worlwide-water_standars_for_hemodialysis
1. Hemodialysis International 2007; 11:S18–S25
Worldwide water standards for
hemodialysis
Richard A. WARD
Department of Medicine, University of Louisville, Louisville, Kentucky, U.S.A.
Abstract
Contaminants commonly found in tap water are toxic to hemodialysis patients. To prevent patient
injury from these contaminants, standards for the quality of water used to prepare dialysate have
been developed. These standards are in general agreement concerning maximum allowable levels of
inorganic chemical contaminants known to have adverse consequences for dialysis patients. There
is less agreement about inorganic chemical contaminants that may be toxic, and most standards
omit any requirements for organic chemical contaminants. There are considerable differences be-
tween standards regarding the maximum allowable levels of microbiological contaminants, as well
as the methods to be used for measuring them. Harmonization of existing standards may improve
patient protection by promoting demonstrated best practices. Harmonization will require innovation
and compromise to produce a standard that is widely applicable, provides patients with the neces-
sary safeguards, and whose requirements can be routinely achieved within the constraints imposed
by local reimbursement practices.
Key words: Hemodialysis, water, standards, harmonization
INTRODUCTION patients developed symptoms of hypercalcemia.3 Recog-
nizing that these problems were related to high levels
When hemodialysis was first introduced as a treatment
of calcium in the municipal water, nephrologists began
for end-stage renal failure in the 1960s, dialysate was
treating the municipal water with a softener before it was
formulated by adding various salts, and often glucose, to used to prepare dialysate.2,3
tap water. Once the more pressing technical challenges of
By the mid-1970s, aluminum, chloramines, copper,
dialysis, such as blood access, were addressed and pa-
and fluoride had been identified as being definitely or
tients began to survive for longer times and in greater
probably toxic to hemodialysis patients.1 For aluminum
numbers, it became apparent that dialysate prepared from
and chloramines, this toxicity was evident at concentra-
tap water could contain substances that were harmful to
tions commonly found in municipal water supplies. In
hemodialysis patients or that caused problems with he-
addition, the incidence of pyrogenic reactions during
modialysis machines.1 As these substances were identi-
hemodialysis was observed to correlate with the level of
fied, individual nephrologists began to change their bacteria in the dialysate.4 Thus, it was clear that the water
practices. For example, in areas where municipal water
used to prepare dialysate needed purification to ensure
supplies contained high levels of calcium and magnesium
low levels of these contaminants. This realization was the
(hard water), the fluid pathways of dialysis machines
start of the development of fluid quality standards for
became fouled with carbonate precipitates2 and some
hemodialysis, a process that continues to the present day.
The purpose of this paper is to review the evolution of
Correspondence to: R. A. Ward, PhD, Kidney Disease quality standards for water used in hemodialysis applica-
Program, University of Louisville, 615 S. Preston Street, tions and discuss some of the issues that may influence
Louisville, KY 40202-1718, U.S.A. the development of these standards at the beginning of
E-mail: richard.ward@louisville.edu the 21 century.
S18 r 2007 The Authors. Journal compilation r 2007 International Society for Hemodialysis
2. Worldwide water standards for hemodialysis
In the beginning . . . Protection Agency’s National Interim Primary Drinking
Water Standard published in 1975, which set maximum
The idea of a quality standard for water used in hemo- contaminant levels for substances that had been deter-
dialysis appears to have been considered first in the mined to be hazardous to the health of the general popu-
United States in the late 1960s, when the Association lation. Because hemodialysis patients have a much greater
for the Advancement of Medical Instrumentation (AAMI) exposure to water than a person with normal renal func-
and the American Society for Artificial Internal Organs tion, because the gradient for transfer from dialysate to
(ASAIO) began a collaborative effort to write a standard blood may be maintained throughout dialysis because of
for hemodialysis machines. A tentative draft of that stand- protein binding, and because hemodialysis patients lack
ard was published for comment in 1970. This initial draft renal excretion, the maximum allowable levels for these
suggested that the quality of water used to prepare dial- substances was set at one-tenth of the EPA maximum al-
ysate should meet the requirements of the United States lowable level for drinking water or the no-transfer level.
Pharmacopoeia for purified water, with an additional (The no-transfer level for a solute is defined as that dial-
limit on heavy metals (o0.01 mg/L) and a minimum re- ysate concentration at which there will be no net transfer
sistivity of 1 MO cm at 25 1C if deionized water was used. of the solute across the dialyzer membrane, given a nor-
This draft underwent numerous revisions over the next 9 mal plasma concentration of the solute.) The maximum
years, and it was not until 1979 that the AAMI Renal allowable level of bacteria in the water was based on the
Disease and Detoxification Committee finally reached observation that the incidence of pyrogenic reactions was
agreement on its content. About the same time, Prakash significantly increased if the level of bacteria in the dial-
Keshaviah at the Minneapolis Medical Research Founda- ysate exceeded 2000 CFU/mL.4 Experience suggested that
tion, under contract to the United States Food and Drug dialysis machines in use at the time the standard was
Administration, was preparing a report identifying the being developed could amplify the bacterial burden in the
risks and hazards associated with conventional hemodi- water by a factor of 10. Therefore, the maximum allow-
alysis systems. Because of the potential overlap between able level of bacteria in the water was set at 200 CFU/mL.
these 2 endeavors, the AAMI Renal Disease and Detoxi-
fication Committee decided to wait for Keshaviah’s report Current water quality standards and
before finalizing their standard. Keshaviah’s report ap-
peared in June 19805 and many of its recommendations
recommendations
were incorporated into the first AAMI standard for he- In the years since the AAMI standard was first published,
modialysis systems, which was finally published in May many other countries have established standards or rec-
1982.6 A parallel effort took place in Canada, with the ommendations for the quality of water used in hemo-
Canadian Standards Association publishing a draft stand- dialysis. These standards and recommendations have
ard (CSA Standard Z364.2) in 1978. been prepared by standards organizations (e.g., Canadi-
The AAMI standard established maximum levels of a an Standards Association,7 American National Standards
range of chemical contaminants and bacteria in the water Institute/AAMI,8 International Organization for Standard-
used to prepare dialysate (Tables 1 and 2), as well as a ization [ISO]9), pharmacopoeias (e.g., Europe,10 United
maximum level of bacteria in the final dialysate. The States11), and professional associations (e.g., European
water quality requirements of the Canadian standard Renal Association-European Dialysis and Transplant
were substantially the same as those in the AAMI stand- Association [ERA-EDTA],12 Japanese Society for Dialysis
ard. The substances covered by these standards could be Therapy13). While there is general agreement concerning
divided into 4 groups (Tables 1 and 2): substances with the maximum allowable levels of inorganic chemicals
documented toxicity in hemodialysis patients; substances with documented toxicity in hemodialysis patients (alu-
normally included in dialysate; other trace elements; and minum, chloramines, copper, fluoride, lead, nitrate, sul-
microbiological contaminants. For substances with doc- fate, and zinc), there are some exceptions. For example,
umented toxicity in hemodialysis patients, the maximum the current edition of the European Pharmacopoeia does
levels were set at values less than the lowest level at which not explicitly specify maximum allowable levels for cop-
toxicity had been documented. For substances normally per or chloramines. In the latter case, the European Phar-
included in dialysate, the maximum levels were set so that macopoeia does specify a maximum allowable level for
the water would not significantly affect the final dialysate total available chlorine and provides a test method that
composition. The other trace elements included in the will detect both free chlorine and chloramines.10 As the
standard were based on the United States Environmental maximum allowable level for total available chlorine is set
Hemodialysis International 2007; 11:S18–S25 S19
3. Ward
Table 1 Recommended maximum concentrations of chemical contaminants in water used for hemodialysis
Canadian Standards United States European
Contaminant (mg/L) AAMI8 Association7 Pharmacopoeia11 Pharmacopoeia10
Substances with documented toxicity in hemodialysis patients
Aluminum 0.01 0.01 0.01 0.01
Chloramines 0.10 0.10 0.10 —
Free chlorine 0.50 — 0.50 —
Total available chlorine — — — 0.1
Copper 0.10 0.10 0.10 —
Fluoride 0.20 0.20 0.20 0.20
Lead 0.005 0.005 0.005 —
Nitrate (as N) 2.00 2.00 2.00 2.00
Sulfate 100 100 100 50
Zinc 0.10 0.10 0.10 0.10
Substances normally included in dialysate
Calcium 2 2 2 2
Magnesium 4 4 4 2
Potassium 8 8 8 2
Sodium 70 70 70 50
Other substances
Ammonia — — — 0.2
Antimony 0.006 0.006 0.006 —
Arsenic 0.005 0.005 0.005 —
Barium 0.10 0.10 0.10 —
Beryllium 0.0004 0.0004 0.0004 —
Cadmium 0.001 0.001 0.001 —
Chromium 0.014 0.014 0.014 —
Chloride — — — 50
Mercury 0.0002 0.0002 0.0002 0.001
Selenium 0.09 0.09 0.09 —
Silver 0.005 0.005 0.005 —
Thallium 0.002 0.002 0.002 —
Total heavy metals — — — 0.10
Total organic carbon — 0.500 — —
AAMI =Association for the Advancement of Medical Instrumentation.
at the same value as other standards set for chloramines, modialysis water standard because there were no data
there is effectively no difference in quality requirements. documenting their toxicity in hemodialysis patients. The
In addition, there are some differences in how the various extent to which standards for water used in dialysis ap-
standards treat heavy metals and substances normally in- plications should continue to be influenced by drinking
cluded in dialysate (magnesium, potassium, and sodium; water standards remains an open question as discussed
Table 1). Some standards (Canada, United States, ISO) later in this review. Overall, and with the exception of the
specify limits for individual heavy metals, while others omission of copper from the European Pharmacopoeia,
(European Pharmacopoeia) set a limit for heavy metals as there is no compelling evidence of adverse clinical con-
a group. Also, the range of heavy metals included in the sequences arising from the minor differences between
standards has evolved over time. Three additional heavy standards in the allowable levels of inorganic chemical
metals (antimony, beryllium, and thallium) were added to contaminants.
the AAMI standard in 2001 by virtue of their inclusion in Of note, none of the existing standards and recom-
the United States drinking water standard. The AAMI Re- mendations includes limits for specific organic chemical
nal Disease and Detoxification Committee expressed contaminants. The rationale for this omission is that or-
some hesitation about adding these elements to their he- ganic chemicals with specific toxicity to hemodialysis
S20 Hemodialysis International 2007; 11:S18–S25
4. Worldwide water standards for hemodialysis
Table 2 Recommended maximum levels of microbiological able levels of microbiological contaminants in water used
contaminants in water used for hemodialysis for hemodialysis. These differences involve not only the
levels of microbiological contaminants (Table 2) but also
Bacteria Endotoxin the methods used to measure them (Table 3). The original
(CFU/mL) (EU/mL) AAMI standard set a maximum allowable level for bac-
AAMI8 200 2 teria of 200 CFU/mL. Subsequently, other stand-
Canadian Standards Association7 100 2 ards7,10,11,16 and recommended practices12,17 set the
United States Pharmacopoeia11 100 2 level at 100 CFU/mL, which is not substantially different
European Pharmacopoeia10 100 0.25
from 200 CFU/mL, given the variability inherent in using
Swedish Pharmacopoeia16 100 0.25
plate counts to determine bacterial levels. As discussed
ERA-EDTA12a 100 0.25
Japanese Society for — 0.25 later, however, there may actually be significant differen-
Dialysis Therapy13 ces in the allowable level of bacteria, depending on what
Italian Society of Nephrology17a 100 0.25 culturing methods are specified. The original AAMI
a
standard did not set a limit for endotoxin because, at
Both the ERA-EDTA and the Italian Society of Nephrology recom-
that time, no convenient test for endotoxin was available.
mend that all dialysis facilities aim for ultrapure dialysate.
AAMI =Association for the Advancement of Medical Instrumenta- In 2001, the AAMI standard was revised to include a
tion; ERA-EDTA = European Renal Association-European Dialysis maximum allowable level of endotoxin of 2 EU/mL meas-
and Transplant Association. ured using the Limulus amebocyte lysate assay. This change
took place after a lengthy debate about whether or not
there was sufficient clinical evidence to support inclusion
of a maximum allowable level of endotoxin. This cautious
patients have not been identified and that carbon adsorp- approach is in marked contrast to the position taken in
tion and reverse osmosis should remove most organic Europe and Japan, where a considerably lower maximum
compounds. That hemodialysis patients may be at risk allowable level of endotoxin (0.25 EU/mL) was intro-
from organic compounds is evidenced, however, by re- duced during the 1990s. Indeed, many authorities advo-
cent reports from Italy describing contamination of water cate even lower maximum allowable levels for bacteria
by organo-halogenated compounds that were not re- and endotoxin (0.1 CFU/mL and 0.03 EU/mL, respective-
moved by standard hemodialysis water treatment prac- ly), although so far these levels remain recommendations,
tices,14,15 including the use of activated carbon and rather than requirements. Fluids meeting this more rig-
reverse osmosis. The Canadian standard7 does include a orous quality standard are referred to as ‘‘ultrapure.’’18
maximum allowable level for total organic carbon Low levels of endotoxin and other bacterial products in
(0.5 mg/L); however, it is not clear that meeting this re- dialysate have been implicated in the low-level chronic
quirement would protect against toxic levels of many or- inflammation observed in hemodialysis patients. Use of
ganic compounds. ultrapure fluids is believed to ameliorate this inflamma-
In contrast to chemical contaminants, there are signif- tion and delay or reduce the severity of long-term com-
icant differences in the recommended maximum allow- plications of hemodialysis therapy, such as malnutrition,
Table 3 Recommended method for determining bacterial levels in water used for hemodialysis
Incubation Incubation
Culture medium temperature ( 1C) time (hr)
AAMI8 TSA 35 to 37 48
Canadian Standards Association7 TSA, SMA, R2A 35 48
United States Pharmacopoeia11 TSA 30 to 35 48
European Pharmacopoeia10 R2A 30 to 35 120
Swedish Pharmacopoeia16 TGEA 22 120
ERA-EDTA12a R2A 20 to 22 144
Italian Society of Nephrology17a TGEA, R2A 20 to 23 120 to 144
a
Both the ERA-EDTA and the Italian Society of Nephrology recommend that all dialysis facilities aim for ultrapure dialysate.
AAMI =Advancement of Medical Instrumentation; ERA-EDTA = European Renal Association-European Dialysis and Transplant Association;
R2A = Reasoner’s 2A; SMA = standard methods agar; TGEA = tryptone glucose extract agar; TSA = tryptic soy agar.
Hemodialysis International 2007; 11:S18–S25 S21
5. Ward
b2-microglobulin amyloidosis, resistance to erythropoie- best practices and a standard that is enforced as a regu-
tin, and loss of residual renal function.19 lation. Both models, as well as various hybrid versions,
In addition to differences in the maximum allowable are currently in use around the world. For example, in
levels of endotoxin, there are important differences the United States, compliance with the AAMI standard
between standards in the methods recommended for for water quality is required if a facility is to receive pay-
measuring bacterial contamination. The original AAMI ment for hemodialysis services from the United States
standard allowed the use of tryptic soy agar (TSA), stand- Government’s Medicare program and compliance is
ard methods agar (SMA), or blood agar, with enumeration monitored by periodic inspections of dialysis facilities.
of colonies after incubation for 48 hr at 37 1C.6 It was In contrast, compliance with standards is either not
soon realized that the nutrient-rich environment pro- required or not enforced by inspection in many other
vided by blood agar was not appropriate for culturing jurisdictions. A quality standard enforced as a regulation
organisms adapted to a purified water environment and must be capable of being met routinely by a typical dia-
the use of blood agar was eliminated as an option in sub- lysis facility at a cost consistent with local reimbursement
sequent versions of the standard.8 Later studies also practices. In contrast, a standard intended as a guide to
showed that the combination of TSA and incubation at best practices may recommend a level of quality that can
37 1C for 48 hr was not optimal for recovery of water- be met only by commitment of additional resources at the
borne organisms. Use of nutrient-poor media, such as discretion of an individual dialysis facility that believes
Reasoner’s 2A and tryptone glucose extract agar, and that level of quality will be of benefit to its patients. A
longer incubation times at room temperature resulted in harmonized standard should be capable of serving both
colony counts that were often an order of magnitude functions.
higher than those obtained with TSA incubated for 48 hr It may be possible for a standard to serve both a regu-
at 37 1C.18 These more stringent culturing conditions latory and an advisory role by including 2 grades of water
have been adopted in whole, or in part, by several or- quality in the standard. The first grade would establish
ganizations issuing standards or recommendations for the maximum allowable concentrations of contaminants
quality of water used for hemodialysis (Table 3). based on definitive evidence that higher concentrations
of a contaminant would be harmful to patients. The sec-
ond grade may recommend a lower concentration of a
Where do we go from here? contaminant where there was a suggestion that the lower
Some in the dialysis community believe that the time is concentration may be associated with improved patient
right to harmonize existing quality standards for water outcomes. This approach has been used by the ERA-
used in hemodialysis applications. It is suggested that a EDTA and the Italian Society of Nephrology, which have
harmonized standard would help disseminate demon- adopted the European Pharmacopoeia quality standard
strated best practices in countries with well-established for maximum allowable levels of contaminants, but rec-
hemodialysis programs, thereby decreasing the likelihood ommend the use of ultrapure fluids.12,17
of both acute and chronic adverse events related to water As is evident from Tables 1 and 2, there are some dif-
quality. It could also serve as a guideline for countries ferences in the range of contaminants included in the
where chronic hemodialysis is still in its infancy. Finally, a various standards and recommendations, as well as in the
harmonized standard may contribute to better technology maximum allowable level of individual contaminants. A
for water purification and distribution by establishing harmonized standard would require a resolution of these
a consistent set of expectations for equipment manufac- differences.
turers. Current efforts to revise and expand the ISO’s As mentioned previously, some current standards do
standards related to fluids used for hemodialysis may act not explicitly include chloramines even though their tox-
as an impetus to harmonization. Before harmonization icity in hemodialysis patients has been documented re-
can occur, however, 2 important questions must be an- peatedly over 30 years.20,21 It has been argued that there
swered: Is harmonization desirable and feasible; and, how is no need to include chloramines in a standard for a
should the maximum allowable levels of contaminants be region where chloramines are not used to disinfect
determined? municipal water supplies. However, patient injury has
The desirability and feasibility of harmonizing water occurred in many parts of the world when municipal
quality standards depend, in part, on how such standards water providers began using chloramines with little or no
are used. There is a significant difference between a prior notice to dialysis facilities. For this reason, it seems
standard used to provide guidance on demonstrated reasonable that a harmonized standard should include all
S22 Hemodialysis International 2007; 11:S18–S25
6. Worldwide water standards for hemodialysis
contaminants with documented toxicity in hemodialysis about the strength of the evidence for strontium toxicity
patients. The benefits of avoiding toxicity almost certainly and the concentration at which it occurs.
outweigh the cost of routine monitoring for these con- Microbiological contaminants present a particular
taminants. problem in trying to reach consensus on maximum al-
Whether or not to include contaminants that have no lowable levels of contaminants. As described earlier, cur-
documented toxicity in hemodialysis patients is a more rent standards differ significantly in the maximum
difficult question. Heavy metals were included in the ori- allowable level of endotoxin. Further, even though there
ginal AAMI standard because their levels in drinking does not appear to be a large difference in plate count
water were regulated as a matter of public health and values, in reality, there may be significant differences in
because they were thought to pose a greater risk to he- the maximum allowable level of bacteria because of dif-
modialysis patients because of the mechanism of expos- ferences in recommended culturing methods. In general,
ure and the lack of renal excretion. Other standards have European and Japanese standards set a lower maximum
chosen to deal with heavy metals collectively by estab- allowable level for endotoxin than the United States
lishing a maximum allowable level for them as a group. standard (Table 2). In addition, there is widespread sup-
Neither approach is entirely satisfactory. Including a sub- port for the use of ultrapure fluids in both Europe and
stance in the standard because it is included in drinking Japan, based on a growing literature showing improve-
water regulations implies that any substance added to the ments in outcomes such as nutrition and anemia correc-
drinking water regulations should be added to the he- tion when ultrapure dialysate is used. Some in the United
modialysis water standard. This situation has arisen in the States dialysis community argue, however, that the evi-
United States, leading to the addition of antimony, beryl- dence used to support lower levels of endotoxin and, in
lium, and thallium to the hemodialysis water standard in particular, ultrapure dialysate is not convincing. They cite
2001 even though there was no evidence that they posed the absence of controlled clinical trials comparing out-
a particular risk to hemodialysis patients. This open- comes obtained with lower levels of endotoxin, including
ended, non-evidence-based approach only serves to in- ultrapure dialysate, with those obtained with dialysate
crease the cost and complexity of monitoring water for meeting the current United States quality standards. They
hemodialysis without any apparent benefit to patients. also worry about the cost and feasibility of routinely
Combining the heavy metals into a single group is attrac- meeting a more stringent quality standard in a regulated
tive as it has the potential to reduce the cost of routine environment where reimbursement is tightly controlled.
water analyses. However, treating heavy metals as a With regard to water, these arguments may be somewhat
group implies that the maximum allowable level for moot. It should be remembered that patients are treated
the group should not exceed the maximum allowable with dialysate, not water, and it is the microbiological
level for the most toxic member of that group. Cur- quality of the dialysate that is important. In general, ultra-
rently, maximum allowable levels for 10 heavy metals pure dialysate is prepared by point-of-use filtration of the
included in the standards that list each heavy metal dialysate immediately before it enters the dialyzer. Clearly,
individually are below the 0.1 mg/L level set in the Eu- higher quality water reduces the burden on the final ul-
ropean Pharmacopoeia for total heavy metals. At this trafilter; however, currently available point-of-use ultra-
point, it remains unclear how best to deal with trace con- filtration systems should be capable of producing
taminants, with no clearly defined toxicity in the setting ultrapure dialysate from concentrates and water that rou-
of hemodialysis. tinely meet any of the quality standards listed in Table 2.
However this issue is resolved, an effective standard Thus, the cost aspect of ultrapure dialysate shifts from
should incorporate a mechanism for promptly adding a debate about whether or not the quality of the water
new substance that may, in the future, be shown to be used to prepare the dialysate should be ultrapure to
toxic to hemodialysis patients. Although candidate toxins whether or not to install point-of-use ultrafilters for the
are rare, examples have appeared in recent years. Lead, final dialysate.
which was included in the original AAMI standard be- All of these arguments are predicated on the assump-
cause its levels were regulated in drinking water, was re- tion that endotoxin levels are an adequate measure of
ported recently to be toxic in hemodialysis patients,22 water quality. Endotoxin testing reveals nothing about the
although the level at which toxicity occurs is not well levels of other microbiological contaminants, including
defined. Strontium contamination of water used to pre- yeasts, fungi, peptidoglycans, and fragments of bacterial
pare dialysate has been implicated in bone disease in he- DNA, all of which have been identified in water used for
modialysis patients,23,24 although there is still debate hemodialysis.25–27
Hemodialysis International 2007; 11:S18–S25 S23
7. Ward
SUMMARY 7 Canadian Standards Association. Water Treatment Equip-
ment and Water Quality Requirements for Hemodialysis,
Hemodialysis patients are at risk from contaminants in Z364.2.2-03. Toronto, ON: Canadian Standards Associa-
the water used to prepare dialysate. To mitigate this risk, tion; 2003.
various organizations have developed standards and rec- 8 Association for the Advancement of Medical Instru-
ommendations for water quality over the past 25 years. mentation. Water Treatment Equipment for Hemodialysis
There is general agreement concerning maximum allow- Applications, ANSI/AAMI RD62:2001. Arlington, VA: As-
able levels of inorganic chemical contaminants known to sociation for the Advancement of Medical Instrumenta-
have adverse consequences for dialysis patients. There is tion; 2001.
less uniformity when it comes to inorganic chemical con- 9 International Organization for Standardization. Water for
taminants that may have toxicity and an almost complete Haemodialysis and Related Therapies, ISO 13959:2002(E).
silence in the area of organic chemical contaminants. Geneva: International Organization for Standardization;
Further, there are considerable differences between the 2002.
10 European Pharmacopoeia Commission. European
various standards and recommendations regarding the
Pharmacopoiea, 5th ed. Monograph 2005:1167, Haemodi-
maximum allowable levels of microbiological contamin-
alysis Solution, Concentrated, Water for Diluting. Stras-
ants and the methods to be used for measuring these bourg: European Pharmacopoeia Commission; 2005.
contaminants. Harmonization of the various standards 11 United States Pharmacopoiea. h1230iWater for health
and recommended practices may help protect patients by applications, water for hemodialysis. First supplement to
promoting demonstrated best practices and providing a USP 28-NF 23, 2005.
road map for those countries where large-scale hemodi- 12 European Renal Association-European Dialysis and
alysis is still in its infancy. Achieving harmonization will Transplant Association. European best practice guidelines
require innovation and compromise to produce a stand- for haemodialysis (part I), section IV: Dialysis fluid purity.
ard that is widely applicable, provides patients with the Nephrol Dial Transplant. 2002; 17(Suppl 7):45–62.
necessary safeguards, and whose requirements can be 13 Morii K, Morii H, Asano Y, Naitoh H, Takesawa S. Stand-
routinely achieved within the constraints imposed by ard for safety of dialysis fluid. J Jpn Soc Dial Ther. 1998;
local reimbursement practices. 31:1107–1109.
14 Formica M, Vallero A, Forneris G, et al. Organo-haloge-
nated contamination of a dialysis water treatment plant.
G Ital Nefrol. 2002; 19:479–482.
Manuscript received August 2006; revised September 15 Poli D, Pavone L, Tansinda P, et al. Organic contam-
2006. ination in dialysis water: Trichloroethylene as a model
compound. Nephrol Dial Transplant. 2006; 21:1618–
1625.
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