Improving Dialysis Patient Outcomes Introducing ultrapure water to facilitate HiVOLHDF: An engineer’s perspective
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Water quality is fundamental to haemodialysis regardless of the modality; this has two distinct strands namely chemical quality and microbiological quality. However, the water quality is far more critical with the high volume online haemodiafiltration (HiVOLHDF)* modality of treatment. A typical adult will be exposed to approximately fourteen litres of water a week. This is ingested orally, absorbed via the gastrointestinal tract, any excess is removed by the nephron in the kidney and exits the body with other waste products of metabolism in the urine. By contrast, the standard thrice weekly haemodialysis patient is exposed to 576 litres per week via the semipermeable dialyser. In addition, the high volume online HDF patient is exposed typically to an additional 60 L per week which is infused directly into the patient’s blood stream. Furthermore, as the majority of End Stage Renal Disease (ESRD) patients have zero, or very minimal residual renal function, toxins in the blood remain and cannot be ‘renally’ excreted between dialysis sessions.
From the literature review, it has been unequivocally demonstrated that water quality is an essential component to the dialysis process. However, as of 2016 there is not a scientific consensus with regard to whether HiVOLHDF is a superior treatment of ESRD patients with regard to mortality and morbidity. Whilst this may be the current case, it is the author’s belief that this will be forthcoming in due course. In the interim, it should be considered best practice to strive towards implementation of ultrapure water systems in all dialysis units and performing HiVOLHDF, while we await the evidence. This viewpoint is compounded by the fact that there have been no negative reports from the studies reviewed relating to patient outcomes when treatment by HiVOLHDF versus alternative conventional haemodialysis treatments
In addition, it would definitely seem prudent that when designing new dialysis facilities, ultrapure water should be considered the standard specification. This organisational development involved the transfer of an existing haemodialysis unit to a new state-of-the art redeveloped facility within the organisation. This facility would offer ultrapure water to facilitate HiVOLHDF as standard. There were numerous change strands to this project and the author incorporated the HSE change model and the CIPP evaluation framework to evaluate and guide the process.
*The acronym HiVOLHDF has been developed by the author for the purpose of this project.