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Faculty of Engineering and Technology, Department of Biomedical Engineering University of Ilorin, P.M.B 1515, Ilorin, Kwara State, Nigeria, 240003 (E-mail: or Tel: +2348033440849 or +2348055275597

Abstract: Over 15,000 new cases of end stage renal disease requiring dialysis emerge each year in Nigeria and much more worldwide. Renal diseases often develop slowly and the symptoms only appear at later stages when the patient already has advanced kidney failure and may even need dialysis or renal replacement therapy to live. Statistics showed that many Nigerians with kidney problems were not aware of their health challenges. Water treatment for preparation of dialysate is probably the most neglected area of renal replacement with dialysis. Quality of water contributes very significantly in morbidity and life threatening reactions in dialysis patients in both; an acute as well as in chronic diagnosis. Heamodialysis is one method of treating renal disease patient. Haemodialysis patients are exposed to between 25 to 30 times of water during their daily therapy compared to normal individuals drinking water needs. Contaminants enter the blood compartment of dialyzers (artificial kidneys) and accumulate in the body due to inability of these patients to excrete them via their kidneys. Hence, it is very important to provide good and well designed water treatment system for heamodialysis of patient with renal failure. This paper addresses how to design appropriate and efficient pure water treatment system using reverse osmosis and other filtration equipment for medical application such as haemodialysis.

Key words: reverse osmosis, haemodialysis, water treatment system, renal disease, dialysis machines, and membrane.


Kidney or renal failure can broadly be divided into two categories: acute kidney injury or chronic kidney disease. The type of renal failure is determined by the trend in the serum creatinine. Biochemically, it is typically detected by an elevated serum creatinine. In the science of physiology, renal failure is described as a decrease in the glomerular filtration rate ( Acute kidney failure usually occurs as the result of a sudden interruption in the blood supply to the kidney, or as a result of a toxic overload of the kidneys. Some causes of acute failure include accidents, injuries or complications from surgery where the kidneys are deprived of normal blood flow for an extended period of time. There are many causes of chronic kidney disease. The most common cause is diabetes mellitus, long-standing uncontrolled hypertension and glomerulonephritis (Adebayo, 2012). In Nigeria, there is little or no access to renal replacement transplant, meaning many people simply die. Kidneys remove waste products from the blood and also remove excess fluid. If the kidneys fail the filtering must be done by artificial kidney and blood pressure may have to be controlled by medication. The End Stage Renal Disease (ESRD) is when kidney function is so bad that one is likely to die within weeks or months unless special treatment such as dialysis or transplantation is given ( There are several different treatment options, such as Peritoneal Dialysis (PD), Continuous Ambulatory Peritoneal Dialysis (CAPD), Haemodialysis, and Kidney Transplant (Ward et al, 1982). According to a report from the Control Disease Center (CDC) of United States of America based on survey of Dialysis associated hepatitis and other disease, it was reported that 1 % centers used no water treatment, 50% used reverse osmosis, 13% used deionization, 33 % combination of reverse osmosis and deionization and 2% used other combination (Rajapurkar, 1994). During dialyses contaminants could enter the blood compartment of dialyzers and accumulate in the body due to inability of these patients to excrete them via their kidneys. Several reports have appeared in literature describing the toxic effects of various contaminants (Rajapurkar, 1994). These are shown in Table 1.

Table 1: Toxic effects of water contaminants in haemodialysis patients CONTAMINANTS Aluminum Calcium / Magnesium Chloramines Copper Fluoride Sodium Microbial Nitrate High Iron Sulfate Zinc Aromatic Hydrocarbons TOXIC EFFECTS Dialysis encephalopathy, Renal Bone Disease Hard water Syndrome, Hypertension, Hypotension Haemolysis, Anemia, Methaemoglobinaemia Nausea, Headache, Liver Damage, Fatal Haemolysis Osteomalacia, Osteoporosis Hypertension, Pulmonary edema, Confusion, Headache, Seizure, Coma Pyrexia Reaction, Chills, Fever, Nausea Shock Methaemoglobinaemia, Hypotension, Nausea Haemosiderosis Nausea, Vomiting, metabolic Acidosis Anemia, Vomiting, Fever Potential Chemical Carcinogens

The Association for the Advancement of Medical Instrumentation (AAMI) has defined haemodialysis water quality standards for chemical contaminants and test methodology. These are shown in Table 2. The use of bicarbonate dialysis is increasing common in haemodialysis due to recognition of complications of acetate dialysis both immediate as well as long term. In Japan almost100% and in Europe 40% patients are on bicarbonate dialysis. The bicarbonate concentrate has been documented to have increased susceptibility to microbial contamination (Rajapurkar, 1994). Hence, water used in mixing the concentrate must be free of contaminants. In order to remove all the contaminants indicated in Table 1 and to conform to the chemical contaminants standards (AAMI) shown in Table 2, a well designed water treatment system is necessary.

Table 2: AAMI Chemical Contaminants Standards for Haemodialysis

METHODOLOGY An extensive dialysis water treatment system is absolutely critical for haemodialysis. Since dialysis patients are exposed to immense quantities of water, which is mixed with dialysate concentrate to form the dialysate; traces of mineral contaminants or bacterial endotoxins can filter into the patient's blood. Because the damaged kidneys cannot perform their intended function of removing impurities, ions introduced into the bloodstream via water can build up to hazardous levels, causing numerous symptoms or death. For example aluminum, chloramines, fluoride, copper, and zinc, as well as bacterial fragments and endotoxins, have all caused problems in this regard ( For this reason, the water used in haemodialysis is carefully purified before use. The type of membrane used and the location of some of the equipment in the water treatment processes determine the quality and efficiency of the system. In this paper Reverse Osmosis method containing thin film composite membrane is used in the design of the water treatment system for heamodialysis. Typical equipments used in the water treatment system are shown in Figure 3.

Reverse Osmosis Phenomenon

Reverse Osmosis (RO) is the phenomenon of osmosis which is defined as the passage of a solvent (e.g. pure water) through a semi-permeable membrane into a solution containing dissolved solutes called chemical contaminants, until the hydrostatic pressures on both sides of the membrane reach an equilibrium reach state as shown in Figure 1. The new solution side pressure is represented by water pressure and osmotic pressure. The term Reverse Osmosis implies the reversal of the equilibrium state to form pure water as shown in Figure 1.

Figure 1: Differences between osmosis and reverse osmosis phenomenon


The typical membranes systems used in water treatment systems for dialysis is the thin-film composite membrane and cellulose acetate membrane systems. The thin-film composite membrane consists of ultra-thin membrane, polysolfone layer and non woven web as shown in Figure 2. The thin-film composite FT30 reverse osmosis membrane gives excellent performance for a wide variety of applications and exhibits high rejection of contaminants with very stable long-term operation (Filmtec Technical Bulletin).

Figure 2: Thin-Film Composite Membrane by Filmtec Inc.

Water Treatment System Equipment Requirements for Haemodialysis A typical design of water treatment system for haemodialysis is shown in Figure 3. Initially the water supply cold and hot is blended and temperature-adjusted. The water pressure is then boosted with the aid of pressure to maintain constant pressure required for the reverse osmosis machine. The water supplys pH is corrected by adding an acid or base. The supply water is passed through an automatic backwashed multi-media sediment filter. Multi-media sediment filter usually contain anthracite in the top layer, sand in the second layer, garnet in the third and fourth layers, and gravel in the bottom layer. Next, the water is run through acid washed activated carbon tanks to adsorb organic contaminants such as chlorine and chloramines. Activated carbon is in powder, or granular form; which can be produced from coconut shell, animal bone, hydrocarbon sludge, peat, lignite, bituminous coal or anthracite coal. It also adsorbs organic compounds which produce odor, taste

and color or toxicity in water. The porosity of activated carbon offers an extremely high surface area to volume mass ratio. For example 2.2 pounds of 1,000 square meters per gram of a typical activated carbon, has about the same surface as 100 miles of two lane highway (Alamo Water Manual). Based on the known affinity of activated carbon, the carbon filter should remove the halogenated hydrocarbons (98%), aromatic hydrocarbons (100%), pesticides (100%), PCBs (100%), and phenols (98%) (Wathen, 1989). The location of activated carbon is very important. Activated carbon must not be placed before the RO system that uses tri-acetate type of membrane because it will be damaged by bacteria due to the removal of chlorine by the activated carbon in the supply water. However, once carbon has reached saturation, it must be properly disposed of. The supply water is then passed through an automatic backwashed water softener that uses processed pellet salt (Zeolites) instead of rock salt that can damage the RO membrane. The purpose of the water softener is to remove the hardness in the water. Next the water is passed through the RO unit that removes most of its contaminants before the pure water is stored in the storage tank with conical bottom. The conical bottom tank is for disinfecting purpose, which is enhanced with the upward facing designed sprinkler installed at the water inlet inside the storage tank. A stainless steel distribution pump is installed to distribute and re-circulate the stored RO water, passing through the ultra filtration system for bacteria removal and protection before the various dialysis machines points. The percentage of different contaminants that could be removed at a given temperature and pressure using a thin-film composite membrane manufactured by Filmtec is shown in Table 3. In Table 3, the percent rejections of all the contaminants are greater than 92% except the Formaldehyde 35%, Methane 25%, Ethanol 70% and Urea 70%. It is not recommended to use Deionizer (DI) for the polishing of reverse osmosis product water. This is because when DI is used in the dialysis application, it poses a major bacteria/endotoxins risk for the patient. DI resins have an ion exchange capacity which declines too rapidly, thereby causing leaching of materials used to construct the product water distribution system (Wathen, 1989). The ultraviolet (UV) light also poses a great risk in the system, though it kills bacteria, but the dead bacteria raises the endotoxins levels in the product water (Wathen, 1989). Installation of filters in the range less or equal than 0.1 micron is required to remove the endotoxins.

Figure 3: Water Treatment System Equipment Requirements for Haemodialysis

Table 3: Thin-film composite reverse osmosis membrane specifications Solute (2000 ppm solute, 225 psi, 77oF(25oC), pH 7) Sodium fluoride NaF Sodium cyanide NaCN (pH 11) Sodium Chloride Nacl Silica SiO2 (50 ppm) Sodium bicarbonate NaHCO3 Sodium nitrate NaNO3 Magnesium chloride MgCl2 Calcium Chloride CaCl2 Magnesium sulfate MgSO4 Nickel sulfate NiSO4 Copper sulfate CuSO4 Formaldehyde Methanol Ethanol Isopropanol Urea Lactic acid (pH 2) Lactic acid (pH 5) Glucose Sucrose Molecular Rejection (%) Weight (MW) 42 49 58 60 84 85 95 111 120 155 160 30 32 46 60 60 90 90 180 342 _ 98 97 98 98 98 93 98 99 99 99 99 35 25 70 90 70 94 99 98 99

Chlorinated pesticides (traces) 99 Source: Technical Bulletin Filmtec Membrane. (Free Chlorine Tolerance <0.1 ppm, pH Range: continuous operation is 2-11 and short-term is 1-12).

CONCLUSION The importance of reverse osmosis water treatment system for medical application, such as in renal disease has been discussed in this paper. It is absolutely necessary to monitor the quality of equipment installed in the system. This is done by installing sample pots for tests purposes and oil filled pressure gauges for monitoring pressure differences across the equipments. It is also recommended to use PVC schedule 80 for the system water lines instead of metals to prevent the reaction of the pure water on metals other than stainless steel of high grade. Reverse Osmosis system is built on a simple concept that happen to rely on very sophisticated components. Aside from its application in renal disease, reverse osmosis can be used to produce double pass pyrogen free intravenous fluid and also be used in sterilizers/autoclaves, Magnetic Resonance Image (MRI), Linear Accelerator (LINAC) and medical laboratory equipment.


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