"The average dialysis patient undergoing three times weekly hemodialysis treatment is exposed to around 24,000 liters of dialysis fluid per annum."[Hoenich, Levin and Ronco, How Do Changes in Water Quality and Dialysate Composition Affect Clinical Outcomes? Blood Purif 2009;27:11-15 ]

The Nephros Dual Stage Ultrafilter has a .005 micron pore size and will allow you to comply with the proposed levels of filtration (see chart below). The Nephros DSU is an FDA 510k approved ultrafilter and has a performance life of up to 12 months, post-RO, with frequent use. The DSU is capable of removing endotoxins, as well as; Legionella, Pseudomonas, Stenotrophomonas, Acinetobacter, Klebsiella and Mycobacterium.

Potential areas of use include:

• Post RO/DI to polish the water (acute units) Eliminate possible bacterial build-up due to infrequent use.
  
• After the bicarb mixer on the bicarb central feed line (controls bacteria)
  
• One on the RO line and one on the bicarb line, just as they enter the dialysis machine. This will help clinics get to "Ultrapure" dialysate. Ultrapure dialysate can help lower infection rates and provide a better dialysis treatment. Eliminate bacterial colonization in the RO water loop.
  
• With reuse machines (Renatrons) to provide ultrapure water for clearing the dialyzer prior to use.

AAMI Standards (adopted on 1/26/11)

EPO Data

Reduce EPO Usage with Nephros Dual Stage Ultrafilter
EPO Reduction Using Dual-Stage Ultrafilters (DSU)
Reduction of EPO Usage After Installing Nephros DSU
EPO Savings with Ultrapure Water and Dialysate
The pending changes to hemodialysis reimbursement require the dialysis community to evaluate where costs can be controlled. 
Field Study EPO

Field Tests and Installation Data

Field testing Portable RO
Field testing RO Loop
DSU Filters - Long-term Bicarbonate Filtering
Endotoxin Testing
Reduce or Eliminate Periodic Disinfections
Installing DSU Prior to Dialysis machine
DSU Dialysis Specifications
Nephros DSU - Dialysis Instructions For Use

Ultrapure dialysis fluid: Standard of care? Ingrid Ledebo, Ph.D.

How Do Changes in Water Quality and Dialysate Composition Affect Clinical Outcomes?
Dialysis relies upon the transfer of waste products and electrolytes across a semi-permeable membrane contained in the dialyser facilitated by the dialysis fluid, a fast-flowing electrolyte solution prepared continuously by the mixing of treated water with a concentrated electrolyte solution.

Ultra Pure Water free of endotoxins and bacteria for Dialysis Center Applications.
The DSU rids water of microbial contaminates. Microbial contamination of dialysate can originate from the water treatment system, the water distribution loop, the dialysate concentrated, or the dialysate proportioning system of the the dialsis machine itself.

Ultrapure Dialysate:What is it and should everybody have it?
Richard A. Ward, Ph.D.

Ultrapure Dialysate Reduces Plasma Levels of ß2-Microglobulin and Pentosidine in Hemodialysis Patients
Ryuichi Furuyaa, Hiromichi Kumagaib, Masaaki Takahashic, Koji Sanoa, Akira Hishidad

Inflammation and dialysate quality
Ralf SCHINDLER
Department of Nephrology and Internal Intensive Care Medicine, Charite´-Campus Virchow-Clinic,
Berlin, Germany

Dialysate related cytokine induction and response to recombinant human erythropoietin in haemodialysis patients
Thomas Sitter, Albrecht Bergner and Helmut Schiffl
Department of Nephrology, Medizinische Klinik Innenstadt, Ludwig-Maximilians-Universität, Munich, Germany

Water Treatment / Biofilm / Endotoxins

Bacterial DNA in Water and Dialysate: Detection and Significance for Patient Outcomes

Clinical Effect of Purification of Dialysis Fluids, Evidence and Experience
Department of Nephrology and Intensive Care Medicine, Charité, Campus Virchow-Klinikum, Berlin , Germany

F-FC312 Dialysate Endotoxin Level and Mortality of Hemodialysis Patients in the United States Based on the DOPPS
T. Hasegawa, R. L. Pisoni, J. L. Bragg-Gresham, S. Fukuhara, T. Akizawa, A. Saito, D. Goodkin, E. Young, B. M. Robinson, F. K. Port Fujiyoshida Municipal Hospital, Yamanashi, Japan; Kyoto University Graduate School of Medicine, Kyoto, Japan; Showa University Fujigaoka Hospital, Kanagawa, Japan; Arbor Research Collaborative for Health, Ann Arbor, MI; Showa University School of Medicine, Tokyo, Japan; Tokai University School of Medicine, Kanagawa, Japan; Amgen, Thousand Oaks, CA

Water treatment and monitor disinfection
Gianni CAPPELLI, Marco RICCARDI, Salvatore PERRONE, Moreno BONDI, Giulia LIGABUE,
Alberto ALBERTAZZI Nephrology Dialysis and Renal Transplantation Unit, Department of Biomedical Sciences, University of Modena, Modena, Italy

Biofilm in dialysis water systems
Basically, a biofilm is formed when a structure or a surface has a growth on it of a community of active microorganisms.

Hemodiafiltration

Improvement of Anemia in Hemodialysis Patients Treated by Hemodiafiltration with High-Volume On-Line-Prepared Substituion Fluid
Giuseppe Bonforte Paolo Grillo Simona Zerbi Maurizio Surian

The relevance of convection in clinical practice: A critical review of the literature
Pietro POZZONI, Salvatore Di FILIPPO, Celestina MANZONI, Francesco LOCATELLI
Department of Nephrology and Dialysis, A. Manzoni Hospital, Lecco, Italy