**2. Water source**

The quality of the feedwater must be appreciated when setting up a purification system for dialysis, either in a home or an in-centre setting. On a basic level, the lower the concentrations of contaminants the less elaborate the purification system. For instance, the size, number and types of filters necessary for a water purification installation in an inner city suburb with good quality piped water would be different from those for a rural setting with borehole water. Even within the same city and despite similar purification steps there is a considerable difference in the organic and inorganic substances in municipal water due to the difference in the origin of the water. This can be due to geology in the area of the source water (e.g. high iron or clay content), and local industry or farming practice (e.g. pesticide use or heavy metal contamina‐ tion) in the area.

Rainwater collection tanks are commonly in use in many rural and remote Australian areas. However, this water can also have both microbiological and inorganic contaminants present, due to the roofing materials used and wildlife that have access to the roof (e.g. birds and possums). In one study of 27 households in Brisbane using rainwater tanks, 63% of tank water samples tested positive for E Coli and 78% tested positive for enterococci. [7]

Municipal water is primarily sourced from 2 areas, surface water and groundwater. Ground‐ water includes wells, aquifers and springs. They have less organic materials but higher inorganic ions eg. metals. Surface water, incudes lakes, ponds and rivers and have more organic matter, microbes and contaminants (eg pesticide, sewerage)

There are several processes involved in converting source water to drinking water standard. These include:



**Table 1.** Types of source water

resulting in liver failure [1-3]. There is also evidence that bacteria and bacterial fragments especially gram-negative lipopolysaccharide can induce an inflammatory state contributing

Ultrapure water has more stringent microbiological criteria than standard dialysis water and has become the standard in most dialysis units. This is particularly relevant when considering the increasing use of on-line haemodiafiltration, which necessitates large volumes of ultrapure replacement fluid to be infused directly into the patient bloodstream, without the traditional barrier protection of the dialyser membrane. In addition the use of high flux dialyser mem‐ branes, theoretically may also allow bacterial fragments to cross into the blood compartment hence further necessitating the need for stringent water standards. Use of ultrapure water is associated with improvement in inflammatory and nutritional markers as well as anaemia and

In the home setting much training, education and preparation is necessary prior to a patient safely performing dialysis at home and in turn this is also important with regards to water quality. Patient factors such as dexterity, visual acuity, hygiene, desire to be independent and ability to follow protocols are important. Importantly in the home setting, patients must correctly perform their own chlorine testing, equipment maintenance and WRO disinfection.

This chapter will discuss the various components of the water purification process required for haemodialysis both in the home and in dialysis units. We will also discuss the components of water quality testing and international standards. Finally, with the increasing constraints on water supply, there is a growing awareness of the need for, so called 'green dialysis units',

The quality of the feedwater must be appreciated when setting up a purification system for dialysis, either in a home or an in-centre setting. On a basic level, the lower the concentrations of contaminants the less elaborate the purification system. For instance, the size, number and types of filters necessary for a water purification installation in an inner city suburb with good quality piped water would be different from those for a rural setting with borehole water. Even within the same city and despite similar purification steps there is a considerable difference in the organic and inorganic substances in municipal water due to the difference in the origin of the water. This can be due to geology in the area of the source water (e.g. high iron or clay content), and local industry or farming practice (e.g. pesticide use or heavy metal contamina‐

Rainwater collection tanks are commonly in use in many rural and remote Australian areas. However, this water can also have both microbiological and inorganic contaminants present, due to the roofing materials used and wildlife that have access to the roof (e.g. birds and possums). In one study of 27 households in Brisbane using rainwater tanks, 63% of tank water

samples tested positive for E Coli and 78% tested positive for enterococci. [7]

to erythropoietin resistance, hypotension and a poor nutritional status [4].

can be produced safely [4-6].

218 Updates in Hemodialysis

**2. Water source**

tion) in the area.

where water conservation practices are utilised.

Several instances in the literature highlight the unfortunate morbidity experienced by patients due to a failure to recognize the importance of knowing the source and nature of feed water used for dialysis. One such incident occurred in Brazil in 1996 where 26 patients died from acute liver failure following failure to recognize that the water supply was not being chlori‐ nated. This led to poisoning by bacterial cyanotoxins, which are highly hepatotoxic. [8]
