Avoiding toxicity from water-borne contaminants in hemodialysis: new challenges in an era of increased demand for water.

Water is necessary for all hemodialysis treatments. However, drinking water contains a range of substances that are toxic to patients on hemodialysis. Thus, all dialysis facilities are equipped with a water treatment system that removes those substances from the water before it is used to prepare dialysate. Increased demand for water and ever-evolving drinking water regulations are leading to changes in drinking water quality that may compromise the ability of typical dialysis water treatment systems to adequately remove substances that are known to be toxic or to deal with unexpected increases in other substances of unknown toxicity. In addition to these external challenges to dialysis water quality, the growing recognition that microbial contaminants in dialysate contribute to long-term morbidity has led to more stringent microbiological quality standards for dialysate and a consequent need to control biofilm formation in the fluid pathways involved in dialysate preparation. Avoiding toxicity from water contaminants in this dynamic environment requires a comprehensive approach to water treatment, including flexibility regarding the choice of water treatment processes, close communication with the suppliers of drinking water, and an emphasis on training technicians responsible for monitoring and maintaining all aspects of the fluid handling systems.