Reflection About The Hemodialysis Water Microbiological Quality in Brazil Ⅳ

MONITORING THE QUALITY OF TREATED WATER FOR DIALYSIS

Monitoring intends to reduce the risks caused by microorganisms, providing safety to patients undergoing hemodialysis treatment (Jasson et al., 2010; Riepl et al., 2011). Additionally, it allows directing preventive measures promptly to avoid damage to the patient's health (Figueras, Borrego, 2010; Nazemi et al., 2016)

According to the capacity of the water system and its control indicators, it is important to establish alert and action limits (Clontz, 2009). An alert limit is understood as a signal, that is, a value that, if exceeded, shows that the process has deviated from its normality, thus corrective actions may or may not be necessary. On the other hand, limit action, if exceeded, indicates that the process deviated from normality, requiring corrective actions (Pinto, Kaneko, Pinto, 2015).

HOW LONG DOES IT TAKE FOR CISTANCHE TO WORK?

Therefore, when sample contamination levels reach the alert limit it is desirable that corrective actions, such as water system disinfection, are carried out to prevent contamination from reaching the action level (Coulliette, Arduino, 2013). The action limit definition is inherent to each unit characteristic, generally, it corresponds to 50% of the maximum value established by the current legislation (Kawanishi et al., 2009).

In 1999, the State of São Paulo, in partnership with the Adolfo Lutz Laboratory, implemented the Treated Water Monitoring Program for Hemodialysis. The results obtained during the years of this program execution indicate that the State Dialysis Units have implemented actions to ensure compliance with the water quality standards used in dialysis procedures (Buzzo et al., 2010).

In an article published in 2018 about the monitoring program in the state of São Paulo, the authors conclude that the program still contributes to the improvement of the treated water for dialysis quality, as it can be seen in Figure 4 the percentage of unsatisfactory samples is small. Also in Figure 4, it can be observed that from the first period studied to the last one, there was an increase of unsatisfactory samples, which the authors justify being due to the RDC update in 2014, which set stricter limits and therefore resulted in the need for adjustment in the treatment system by the dialysis units (Buzzo et al., 2018).

After determining the implementation of sanitary surveillance measures in the State of Rio de Janeiro, it was observed an improvement in the quality of the water treated for dialysis during the monitoring program in the period of 2006 - 2007 (Ramirez, 2009). However, in the monitoring realized in the state of Bahia results obtained were in disagreement with the recommended in 31% of the hemodialysis therapy units evaluated (Costa, 2012).

FIGURE 4 - Frequency of unsatisfactory results determined at the initial sample collection as a function of the analyzed parameter (Source: Buzzo et al., 2018).

CONCLUSIONS 

This literature review leads us to reflect on the need to implement monitoring of treated water for dialysis at a national level through appropriate analytical methods that provide results on time allowing corrective actions to be performed immediately because during this therapy the patient needs a large volume of water within the quality standards in order to provide safety to the patient. 

ACKNOWLEDGMENTS

The authors would like to thank the National Council of Scientific and Technological Development (CNPq) for the scholarship.

REFERENCES 

Agar J, Perkins A, Heaf J. Home Hemodialysis: Infrastructure, Water, and Machines in the Home. [citad 2019 Ago 16] Available from: http://www.ishd.org/8-home-hemodialysis-infrastructure-water-and-machines-in-the-home/ 

Agência Nacional de Vigilância Sanitária, Brasil (Anvisa). Resolução nº 33, de 3 de junho de 2008. Regulamento Técnico para planejamento, programação, elaboração, avaliação e aprovação dos sistemas de tratamento e distribuição de água para hemodiálise no sistema nacional de vigilância sanitária. Diário Oficial da União, jun. 2008. Agência Nacional de Vigilância Sanitária, Brasil (Anvisa). Farmacopéia brasileira. 6. ed. Brasília, 2019. v. 1. Agência Nacional de Vigilância Sanitária, Brasil (Anvisa). Resolução nº 11, de 13 março 2014. Requisitos de Boas Práticas de Funcionamento para os Serviços de Diálise e dá outras providências. Diário Oficial União, 14 mar. 2014. Azevedo SMFO, Camichael WW, Jochimsen EM, Rinehart KL, Lau S, Shaw GR, et al. Human intoxication by microcystins during renal dialysis treatment in CaruaruBrazil. Toxicology. 2002;181-182:441-446. Banasik JL, Copstead LEC. Pathophysiology. 7. ed. 

Maryland Heights: Elsevier, 2018. Buzzo ML, Bugno A, Almodovar A AB, Kira CS, Carvalho FH, Souza A, et al., A importância de programas de monitoramento da qualidade da água para diálise na segurança dos pacientes. Rev Inst Adolfo Lutz. 2010;69(1):1-6. 

Buzzo ML, Silva FPL, Hilinski EG, Bugno A. Effectiveness of the monitoring program for ensuring the quality of water treated for dialysis in the state of São Paulo. Braz J Nephrol. 2018;40(4):344-350. 

Canaud B, Rapid assessment of microbiological purity of dialysis water: the promise of solid-phase cytometry assessment and the epifluorescence microscopy method. Nephrol Dial Transplant. 2011;26:3426-3428.