Hemodialysis Water Parameters as Predisposing Factors for Anemia in Patients in Dialytic Treatment: Application of Mixed Regression Models
Contamination by metals and microbiological agents in hemodialysis water can cause clinical intercurrences in hemodialysis patients. Evaluating and assuring minimum levels of contamination from metals and microorganisms in hemodialysis water can improve patient safety. The objective of this study was to assess hemodialysis water quality in a major tertiary hospital in Brazil and investigate the relationship between hemodialysis water quality and clinical intercurrences in hemodialysis patients. A prospective-observational cohort study for evaluation of water quality parameters and clinical intercurrences present by patients (n = 52) were performed from May 2014 to April 2015. Mixed linear regression models and binary regression models were fitted for water quality parameters and patients’ clinical parameters. The increase in the levels of copper and nitrate in hemodialysis water was significant (p < 0.05) to explain anemia. Bone pain was related to age, sex (female), and hemodialysis treatment duration (years). Hypotensive episodes were related to serum sodium decrease. Aluminum in hemodialysis water was present in an average concentration higher than the permitted threshold (15.35 ± 14.53 μg/L). Cadmium, total coliforms, Escherichia coli, and endotoxins in hemodialysis water were not detected and the heterotrophic bacteria count was below the reference limit. These parameters’ concentrations varied during the study, evidencing the need for continuous monitoring.
KeywordsHemodialysis treatment Hemodialysis water quality Clinical intercurrences Cohort study
This study was supported by the Coordination for the Improvement of Higher Education Personnel (CAPES).
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in compliance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved by the ethics committee of the University of São Paulo at Ribeirão Preto College of Nursing (report no. 343.500).
- 2.Brasil (2014) Resolução RDC no. 11, de 13 de março de 2014. Dispõe sobre os Requisitos de Boas Práticas de Funcionamento para os Serviços de Diálise e dá outras providências. Brasília, DF, 14 de março de 2014Google Scholar
- 3.Association for the Advancement of Medical Instrumentation (2014) Water for haemodialysis and related therapies, AAMI/ISO 13959:2014. AAMI, ArlingtonGoogle Scholar
- 4.Buzzo ML, Bugno A, Almodovar AAB, Kira CS, Carvalho FH, Souza A, Scorsafava MA (2010) A importância de programas de monitoramento da qualidade da água para diálise na segurança dos pacientes. Rev Inst Adolfo Lutz 69(1):1–6Google Scholar
- 11.Kidney Disease Improving Global Outcomes (2012) Clinical practice guideline for anemia in chronic kidney disease. Kidney Int Suppl 2(4):279–335. https://doi.org/10.1038/kisup.2012.41
- 12.American Public Health Association (2012) Standard methods for the examination of water and wastewater, 22 st. ed. Washington DC: APHA-AWWA-WEF, 1360 pGoogle Scholar
- 13.Companhia de Tecnologia de Saneamento Ambiental (2009) Análises microbiológicas de amostras ambientais. CETESB, São Paulo 134pGoogle Scholar
- 19.Onufrak SJ, Bellasi A, Cardarelli F, Vaccarino V, Muntner P, Shaw LJ, Raggi P (2009) Investigation of gender heterogeneity in the associations of serum phosphorus with incident coronary artery disease and all-cause mortality. Am J Epidemiol 169(1):67–77. https://doi.org/10.1093/aje/kwn285 CrossRefPubMedGoogle Scholar
- 22.Abensur H (2004) Anemia da doença renal crônica. J Bras Nefrol 21(3):26–18Google Scholar
- 28.Ziebarth A (1991) Well water, nitrates and the blue baby syndrome methemoglobinemia. University of Nebraska, Lincoln, NebraskaGoogle Scholar
- 31.Agency for Toxic Substances and Disease Registry (2008) Toxicological Profile for Aluminum. ATSDR, U.S. Department of Health and Human Services, Public Health Services, Atlanta, GA 357pGoogle Scholar
- 32.Bonadio SL, Paschoalato CFPR, Júnior RP, Innocentini MDM (2005) Avaliação da qualidade da água do rio Pardo na região de Ribeirão Preto. http://www.bvsde.paho.org/bvsaidis/uruguay30/BR08505_Bonadio.pdf
- 34.Sjögren B, Iregren A, Elinder CG, Yokel RA (2007) Aluminium, chapter 17. In: Nordberg GF, Fowler BA, Nordberg M, Friberg L (eds) Handbook on the toxicology of metals, 3° edição edn. Elservier Inc., New York CityGoogle Scholar
- 35.Daugirdas JT, Blake PG, Ing TS (2013) Manual de diálise. 4° edição, Rio de Janeiro: Editora Guanabara Koogan, 744pGoogle Scholar