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Hemodialysis Water: Water that sustains life

According to the Brazilian Society of Nephrology (SBN), Brazil has approximately 172,000 patients undergoing renal replacement therapies, mainly hemodialysis, most of whom are treated by the Unified Health System (SUS) [1].

What is Hemodialysis?

Hemodialysis is a procedure that replaces the function of compromised kidneys. In this therapy, a machine filters the patient’s blood, removing toxic waste and excess fluids [2]. During the process, the blood is taken from the patient by vascular means and propelled with the aid of a pump to the dialysis filter (dialyzer). It is at this point that the blood is exposed to the dialysis solution (dialysate) through a semi-permeable membrane, returning it clean to the patient’s body [2].

Water is an essential component during hemodialysis, being used in large volumes and requiring high purity. Dialysate flow ranges from 500 to 800 mL/min, resulting in 120 to 192 liters of water per session [3]. Considering that patients perform, on average, three weekly sessions of approximately 4 hours each, each patient comes into contact with 300 to 600 liters of water. In addition, there is exposure to potential chemical and biological contaminants, which makes ensuring quality water essential for patient safety [2, 3].

Hemodialysis

Curiosities about hemodialysis

The episode known as the “Hemodialysis Tragedy” in Caruaru, PE in 2016 highlighted the risk of water contamination and reinforced the need for strict regulation of this type of treatment [4]. One of the main standards governing hemodialysis is RDC No. 11 of March 13, 2014, which establishes Good Operating Practice Requirements for Dialysis Services, including microbiological parameters (endotoxins, total coliforms and heterotrophic bacteria counts) and limits for metals and ions such as fluoride, nitrate and sulfate [5].

Microbiological control of hemodialysis water is essential to avoid serious inflammatory reactions in patients. Analyses should be carried out monthly, after the reverse osmosis system and in the distribution loop. Bacterial endotoxins, toxins released by the walls of bacteria even after their death, and the count of heterotrophic bacteria are critical parameters. RDC 11/2014 defines that counts ≥ 100 CFU/mL of heterotrophic bacteria or endotoxin levels 0.25 EU/mL indicate an immediate alert, requiring a review of the water purification system [5]. Any case of fever or suspected infection in patients should prompt an immediate water quality check.

In addition to the microbiological risk, the presence of metals and excess minerals in hemodialysis water represent a significant chemical risk. The accumulation of these substances further overloads already compromised kidneys [6, 7].

  • Aluminum: encephalopathy, osteodystrophy, anemia [6].
  • Copper, lead and zinc: acute or chronic toxicity [6].
  • Fluoride: bone fluorosis [7].
  • Nitrate: methemoglobinemia [7].
  • Sulfate: metabolic acidosis [7].


Ensuring the purity of water in hemodialysis is therefore a guarantee of the patient’s life and safety [6, 7].

EP Analítica services on hemodialysis water

Our laboratory is ABNT NBR ISO/IEC 17025 accreditedensuring that all processes and analyses are carried out with technical rigor and proven reliability. We have highly qualified and trained professionals, as well as state-of-the-art methods and equipment, enabling us to generate consistent and accurate results. With this accreditation, we ensure compliance with current legislation on the quality of water for hemodialysis, offering our clients the confidence that they are receiving services of excellence and total safety for the treatment of their patients.

Karen Fernanda de Oliveira and Karina Cibele de Oliveira

References

  1. BRAZILIAN SOCIETY OF NEPHROLOGY (SBN). Study by the SBN and ABCDT reveals a serious gap in the cost of dialysis in Brazil. SBN – news, July 2, 2025. Available in: https://sbn.org.br/medicos/sbn-acontece/noticias/estudo-nacional-revela-grave-defasagem-no-custeio-da-dialise-no-brasil/. Accessed on: 14 Oct. 2025.
  2. BIEBER, Scott; HIMMELFARB, Jonathan. Hemodialysis. AbdominalKey. Available in: https://abdominalkey.com/hemodialysis/. Accessed on: 14 Oct. 2025.
  3. COULLIETTE, Angela D.; ARDUINO, Matthew J. Hemodialysis and water quality. Seminars in Dialysis, v. 26, n. 4, p. 427-438, jul-ago 2013. DOI: 10.1111/sdi.12113. Available in: https://pubmed.ncbi.nlm.nih.gov/23859187/. Accessed on: 14 Oct. 2025.
  4. ABCDT. Caruaru tragedy: history and consequences. Available at: https://www.abcdt.org.br/caruaru-hemodialise/. Accessed on: 14 Oct. 2025.
  5. NATIONAL HEALTH SURVEILLANCE AGENCY (ANVISA). RDC No. 11, of March 13, 2014 – Good Operating Practice Requirements for Dialysis Services. Available at: https://bvsms.saude.gov.br/bvs/saudelegis/anvisa/2014/rdc0011_13_03_2014.html. Accessed on: 14 Oct. 2025.
  6. JENNEN, Faycal et al. Study of contents of nitrates, fluorides and aluminium in dialysis water in Tunisia. Tunis Méd., v. 83, n. 12, p. 770-776, dec. 2005. Available at: https://pubmed.ncbi.nlm.nih.gov/16450947/. Accessed on: 14 Oct. 2025.
  7. D’HAESE, P. C.; VANHOLDER, R. C. Toxicity of dialysis water: aluminum and other trace metals. Blood Purification, v. 12, n. 1, p. 54-63, 1994.
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