**Treatment**

The dialysis must immediately be discontinued and the blood in the blood tubing set must not be given back to the patient. Antihistaminic, adrenalin or steroid may be administered depending on the severity of the reaction.

#### **Prevention**

It can be considered to sufficiently wash the dialyzers before using them for each patient, to use a dialyzer sterilized by γ-rays or steam if the reaction was due to the use of a dialyzer sterilized by ethylene oxide, to use a membrane that activates the complement more mildly or to make a transition from those using Angiotensin Converting Enzyme (ACE) inhibitor to those using Angiotensin Receptor Blockers (ARB) (Dumler et al., 1987; Daugirdas & Ing, 1988).

#### **Type-B reactions**

Their primary symptoms are chest pain and lower back pain. They appear after 20 to 40 minutes after the beginning of dialysis. The symptoms alleviate or disappear in the progressing hours of the dialysis. Complement activation may be blamed of them although the etiology is not fully known (Jaber&Pereira, 1997). The treatment is similar to that in type-A reactions and is adapted depending on the intensity of the symptoms.

Acute Complications of Hemodialysis 257

et al.,2009). The water system technology used in the hempdialysis process is being improved from day to day to reduce such unwanted effects. Two types of water purification systems are being used, the Pure Water and the Ultrapure Water systems. The Pure Water system is used in the conventional hemodialysis process. The Ultrapure Water purification system is used in many dialysis modalities including online hemodiafiltration, online

The conventional hemodialysis water system conveys the water taken from the water supply into the hemodialysis unit after passing it through the mechanical filter, water softener, carbon filter, reverse osmosis and UV. An endotoxin filter is also available in some systems. In units with no online processing, the purified water is kept in big tanks before carried to the patients and then distributed to the hemodialysis machine of the patients via water tubes. Every part of this system may constitute a reservoir for bacteria. Moreover, chemical contamination can also occur. For this reason, the European Pharmacopeia has developed the hemodialysis water standards. According to these standards, the levels of microbial contamination and bacterial endotoxin are recommended to be < 100 CFU/ml and < 0.25 IU/ml respectively in the conventional regular hemodialysis water system (Lindley & Canaud,2002**)** and < 0.1 CFU/ml and < 0.003 IU/ml in the ultrapure water system ([No authors listed] 2002). The chemical

**Contaminant Methods of analysis Maximun concentration (mg/l)** 

Table 1. Maximum water contaminant levels and methods of analysis recommended by the

European Pharmacopoeia (No authors listed] 2002)

hemofiltration and high flux dialysis ([No authors listed] 2002).

contents of the recommended hemodialysis water are given in the table 1.

Aluminum Atomic absorption spectrometry 0.0100 Antimony Atomic absorption spectrometry 0.0060 Arsenic Atomic absorption spectrometry 0.0050 Barium Atomic absorption spectrometry 0.1000 Beryllium Atomic absorption spectrometry 0.0004 Cadmium Atomic absorption spectrometry 0.0010 Calcium Atomic absorption spectrometry 2 (0.05 mmol/l) Chloramines Colorimetry 0.1000 Chromium Atomic absorption spectrometry 0.0140 Copper Atomic absorption spectrometry 0.1000 Cyanide Spectrophotometric 0.0200 Fluoride Molecular photoluminescence 0.2000 Free chlorine Colorimetry 0.5000 Lead Atomic absorption spectrometry 0.0050 Magnesium Atomic absorption spectrometry 2 (0.08 mmol/l) Mercury Atomic absorption spectrometry 0.0010 Nitrate Colorimetry 2.0000 Potassium Flame photometry 2 (0.08 mmol/l) Selenium Atomic absorption spectrometry 0.0900 Silver Atomic absorption spectrometry 0.0050 Sodium Flame photometry 50 (2.2 mmol/l) Sulfate Turbidimetric method 100 Thallium Atomic absorption spectrometry 0.0020 Zinc Atomic absorption spectrometry 0.1000
