sodium-hypochlorite and Kidney-Failure--Chronic

The authors submit the development of research on multiple use of dialyzers and the present state of the capillary dialysers reuse procedure. At present automated reuse machines are used that utilise ++de-ionized rinsing water or reverse ultrafiltration with or without 0.5% solution of sodium hypochlorite, or 3% solution of hydrogen peroxide. Generally, the sterilisation employs 1-2% formaldehyde and Renalin (stabilised solution of peracetic and acetic acids and hydrogen peroxide); more seldom--5% solution of acetic acid and glutaraldehyde. The pre-rinsing procedure of dialysers could also be performed with these solutions, except formaldehyde. The authors present advantages and disadvantages of every rinsing and sterilising solutions, which are used at present. The protein coat on the dialyzer is removed effectively only with sodium hypochlorite. On the other hand, formaldehyde and Renalin are the most effective sterilising solutions. However, formaldehyde could provide the development of anti-N-like antibodies, and allergic-toxic reactions in some patients. Another problem is a negative effect of formaldehyde on the staff. Renalin's drawbacks are its photosensitivity, a corrosive character and high cost. Multiple use of reprocessed dialyzers in the same patient decreases the cost of haemodialysis by even 70%, not effecting the survival rate. Also it is of considerable medical advantage, i.e. decreases the rate of first use syndrome and improves biocompatibility at subsequent uses of the dialyzers. The decrease of elimination effectiveness is, generally, scarcely noticed, statistically irrelevant and of no essential clinical significance.

Topics: Cost Control; Disposable Equipment; Formaldehyde; Humans; Kidney Failure, Chronic; Poland; Renal Dialysis; Sodium Hypochlorite; Solutions; Sterilization; Water

Topics: Administration, Topical; Adolescent; Anti-Bacterial Agents; Antibiotic Prophylaxis; Catheter-Related Infections; Catheters, Indwelling; Child; Disinfectants; Humans; Kidney Failure, Chronic; Mupirocin; Peritoneal Dialysis; Peritonitis; Pseudomonas Infections; Risk Factors; Skin Care; Sodium Hypochlorite; Staphylococcal Infections; Treatment Outcome

Peritoneal dialysis (PD) is a common maintenance renal replacement modality for children with ESRD frequently compromised by infectious peritonitis and catheter exit site and tunnel infections (ESI/TI). The effect of topical mupirocin (Mup) and sodium hypochlorite (NaOCl) solution was evaluated as part of routine daily exit site care on peritonitis and ESI/TI rates, causative microorganisms, and catheter survival rates.. Retrospective chart review of children on home continuous cycling PD between April 1, 2001 and June 30, 2007 was performed. Infection rates were examined based on exit site protocol used in two different periods: Mup alone, April 1, 2001 to November 17, 2004; and Mup and NaOCl (Mup+NaOCl), November 18, 2004 to June 30, 2007.. Eighty-three patients (mean PD initiation age: 12.1 +/- 5.8 yr) received home PD over 2009 patient months. Annualized rates (ARs) for peritonitis decreased from 1.2 in the Mup period to 0.26 in the Mup+NaOCl period (P < 0.0001). ARs for ESI/TI decreased from 1.36 in the Mup period to 0.33 in the Mup+NaOCl period (P < 0.0001). No infections with Mup-resistant organisms were observed when either Mup or Mup+NaOCl was used for prophylaxis. Gram-negative-organism associated peritonitis decreased from an AR of 0.31 in the Mup period to 0.07 in the Mup+NaOCl period (P < 0.001). Infection-related catheter removal rates decreased from 1 in 38.9 catheter-months in the Mup period to 1 in 94.2 in the Mup+NaOCl period (P = 0.01). Catheter survival rates were longer in the Mup+NaOCl period (Kaplan-Meier, P < 0.009).. The combination Mup+NaOCl in daily exit site care was very effective to reduce PD catheter-associated infections and prolong catheter survival in pediatric patients.

Topics: Administration, Topical; Adolescent; Anti-Bacterial Agents; Catheterization; Child; Disinfectants; Drug Therapy, Combination; Female; Humans; Kaplan-Meier Estimate; Kidney Failure, Chronic; Male; Mupirocin; Peritoneal Dialysis; Peritonitis; Pseudomonas Infections; Retrospective Studies; Skin Care; Sodium Hypochlorite; Staphylococcal Infections; Treatment Outcome

The 'Y' set introduced in the clinical practice in the early 80s with the aim of reducing the peritonitis rate in patients on continuous ambulatory peritoneal dialysis, successfully revolutioned the philosophy of the connection system catheter-container of dialysate, which was the main way of bacterial contamination of the peritoneal cavity. In fact, while the previous connection systems had focused the attention on the reduction of the possible contaminating acts, the 'Y' system, taking into account the fact that soon or later a failure could occur even with the most skilled and compliant patient, introduced the possibility to kill the bacteria with a disinfectant and to remove it and the killed bacteria together with the bacteria eventually still surviving, by flushing the contaminated area. This goal was achieved thanks to a 'Y' shaped connector, having a third way connected to the discharge bag/container, besides the two connected to the new bag and to the catheter. From the 'Y' set have originated all the currently used continuous ambulatory peritoneal dialysis connection systems, where the 'Y' is mounted on the bag side (double-bag systems). However in these systems the disinfectant is no longer used, due to the fear of possible untoward effects on the peritoneal membrane. The groundlessness of this position and the possible further advantages of the use of a disinfectant in combination with the 'Y' are discussed and new 'Y' systems preventing every possibility of accidental entry of disinfectant into the peritoneal cavity are presented.

Topics: Bacterial Infections; Catheters, Indwelling; Disinfectants; Equipment Contamination; Equipment Design; Humans; Infection Control; Kidney Failure, Chronic; Morbidity; Peritoneal Dialysis, Continuous Ambulatory; Peritonitis; Risk Factors; Sodium Hypochlorite; Surgical Instruments; Uremia

Vascular access in hemodialysis is a major point of concern in the management of chronic patients. Although arteriovenous fistula remains as the access of first choice, tunneled central venous catheters are still commonly used. Infection remains the principal cause of catheter dysfunction or loss. Many protocols have been used in order to prevent exit site infections and bacteremia. We describe our experience with the use of sodium hypochlorite, an electrolytic chloroxidizer used as a topical disinfectant. It has been shown to be active against a broad spectrum of potential pathogens and has other specific advantages compared to other cleansing agents, including its non-toxic, non-irritating nature and its low cost. We conclude that sodium hypochlorite solution in different concentrations (10 and 50%) is effective in preventing exit site infections and bacteremia associated with tunneled central venous catheters in chronic hemodialysis patients.

Topics: Bacteremia; Candidiasis; Catheterization, Central Venous; Catheters, Indwelling; Cross Infection; Disinfectants; Dose-Response Relationship, Drug; Equipment Contamination; Humans; Incidence; Infection Control; Kidney Failure, Chronic; Renal Dialysis; Sodium Hypochlorite

Peritoneal catheter exit-site and tunnel infections remain critical problems in patients undergoing peritoneal dialysis. Catheter-related peritonitis occurs in about 20% of patients and exit-site infections are responsible for catheter removal in more than one-fifth of the cases. For the last 2 years in the Department of Nephrology, San Bortolo Hospital, Vicenza, Italy, we have been treating exit-site infections caused by Pseudomonas with sodium hypochlorite packs as well as systemic and local antibiotic therapy. Considering the encouraging results obtained on Pseudomonas infection, we decided to utilize the same schedule for the treatment of exit-site infections caused by other germs which are generally difficult to eradicate to prevent peritonitis and catheter removal. Between 2003 and 2004, 10 patients contracted infection of the exit-site. All patients underwent a swab test because of the reddening and the purulent secretion of the exit-site. The swab resulted positive for Pseudomonas in 7 patients, Corynebacterium sp. in 2 patients, and Candida albicans in 1 patient. All patients were treated with systemic antibiotic therapy or antifungal therapy, local sodium hypochlorite 50% packs. After 15 days all patients were submitted to a swab test of the exit site. In all patients, the swab test resulted negative after 15 days and 1 month, and they could continue peritoneal dialysis. This procedure avoided peritoneal catheter removal and temporary switch to hemodialysis in all patients with exit site infection. The mechanism of action is related to the wide antimicrobial spectrum and the rapid action of sodium hypochlorite possibly creating a protective barrier on the exit-site.

Topics: Anti-Bacterial Agents; Catheters, Indwelling; Cilastatin; Cross Infection; Disinfectants; Drug Therapy, Combination; Humans; Imipenem; Infection Control; Kidney Failure, Chronic; Peritoneal Dialysis; Peritonitis; Pseudomonas Infections; Sodium Hypochlorite

Continuous ambulatory peritoneal dialysis is the first-choice treatment for ESRD in Mexico. Peritonitis is the most frequent cause of morbidity and is among the leading causes of technique failure in our country. Our objective was to compare the efficacy of the standard and double-bag disconnect systems for the prevention of peritonitis in a high-risk population with poor living standards, and high prevalence of malnutrition and diabetes rates.. Episodes of peritonitis registered between July 1989 and June 2003 were included. Patients were divided in conventional and double-bag groups. Between July 1989 and May 1999, all patients used the conventional system. From May 1999, all incident patients were placed on a double-bag disconnect system.. Six-hundred and forty-seven patients started dialysis in the study period, 383 in the conventional group, and 264 in the double-bag. The peritonitis rate observed was 1 episode per 7.2 patient-months in the conventional group, and 1 episode per 25.1 patient-months in the double-bag system (p < 0.001). Cumulative peritonitis-free survival rate at 6 (50 vs. 82%), 12 (27 vs. 69%) and 24 (12 vs. 45%) months, respectively, was significantly lower in the conventional group (p < 0.001). Technique survival at 1 (75 vs. 85%), 2 (68 vs. 80%), and 3 years (50 vs. 80%), was worse in the conventional group (p < 0.001). By multivariate analysis, the only factor associated with peritonitis was the connecting system.. We conclude that switching from a standard to a double-bag system using electrolytically produced sodium hypochlorite disinfectant markedly decreased the peritonitis rate, even in a high-risk population like ours.

Topics: Adult; Disinfectants; Female; Humans; Incidence; Infection Control; Kaplan-Meier Estimate; Kidney Failure, Chronic; Male; Mexico; Middle Aged; Multivariate Analysis; Peritoneal Dialysis, Continuous Ambulatory; Peritonitis; Prevalence; Retrospective Studies; Risk Factors; Sodium Hypochlorite; Vulnerable Populations

Viable and potentially infectious HIV-1 has been recovered from the peritoneal dialysis effluent (PDE) of patients with end-stage renal disease (ESRD) who are infected with the human immunodeficiency virus (HIV). No information had previously been available as to how long HIV-1 could survive in this environment, and no data were available as to how long HIV-1 could survive on peritoneal dialysis exchange tubing (PDET). Therefore, this study was designed to answer these questions. HIV-1 Mn was added to PDE and allowed to incubate at room temperature for 0 to 14 days. Following centrifugation, the cellular component of the PDE mixture was placed in co-culture with peripheral blood mononuclear cells (PBMC) from HIV negative donors. Aliquots from the co-cultures were removed after 14 days and assayed for the HIV-1-P24 antigen. High levels of HIV P24 antigen were recovered up to and including seven days of room temperature incubation. HIV could not be recovered from PDE that had been incubated at room temperature for 10 to 14 days. Ten milliters of HIV-PDE mixture was placed within PDET and incubated at room temperature for 10 minutes. The solution was then removed by gravity drainage. After drying times of 0 to 168 hours, the tubing was flushed with HIV culture medium and placed in co-culture with PBMCs from HIV negative donors. The culture supernatant was assayed for the HIV-1 P24 antigen as a marker of viral replication. High levels of HIV-1 P24 antigen were recovered from the PDET wash for up to and including 48 hours of drying time. No viable virus could be detected for drying times of between 72 and 168 hours. To determine if common disinfectants found in the dialysis unit could inactivate HIV, dilutions of Amukin 50% and household bleach were prepared at final concentrations ranging from 1:32 to 1:2048. These disinfectant solutions were incubated with PDE containing HIV for 10 minutes. The cellular fraction of the PDE was isolated by centrifugation, washed, and placed in co-cultures with peripheral blood mononuclear cells. HIV P24 antigen levels were assayed every three days for 28 days. Amukin 50% and a 10% household bleach solution were effective in killing HIV in PDE at dilutions up to and including 1:512. These results indicate that HIV can survive in PDE at room temperature for up to seven days. HIV can survive on peritoneal dialysis exchange tubing for up to 48 hours. Final dilutions of 1:512 Amukin 50% and 10% household bleach, after 10 minutes o

Topics: Culture Media; Dialysis Solutions; Disinfectants; HIV Infections; HIV-1; Humans; Kidney Failure, Chronic; Kinetics; Peritoneal Dialysis; Sodium Hypochlorite; Time Factors

In 22 patients cuprophane capillary dialyzers reutilized in turn with four sets of liquids were used four times (Andante type in 13 and TAF-12 in 9 patients). The degree of biocompatibility and efficiency of elimination of small molecules was evaluated. During four-time reuse of dialyzers reutilized with sodium hypochlorite and with formaldehyde a reduction of intra-dialysis leukopenia, granulocytopenia and thrombocytopenia was not stated in blood of the patients. Activation of the complement system measured with the quantity of decrease of C3c fraction of the complement in the patients blood after 20 minutes of dialysis reduced essentially only at the fourth reuse of dialyzers (p < 0.01). Creatinine clearance measured always one hour after starting of the dialysis, did not change in succeeding reuse of dialyzers. Reutilization of dialyzers with hydrogen peroxide solution and formaldehyde caused essential reduction of ++intra-dialysis leukopenia and neutropenia (p < 0.001). There was lack of changes in ++intra-dialysis thrombocytopenia. Activation of the complement system was reduced essentially only after the fourth reuse of dialyzers (p < 0.001), but was also essentially lower (p < 0.05) than with dialyzers reutilized with sodium hypochlorite and with formaldehyde. Creatinine clearance practically did not change and at the fourth reuse of dialyzers it decreased on the average by 1.8%. Reutilization with acetic acid already at the second reuse of dialyzers essential (p < 0.001) and deepened decrease of intradialytic leukopenia and neutropenia and the activation of the complement system in course of succeeding reuses. Intradialytic thrombocytopenia was subjected to vestigal, not essential decrease. Creatinine clearance lowered a little but not essentially. At the fourth reuse of dialyzers it was lower on the average by 3.6% than the initial one. Reutilization with Dialina (stabilized blend of peracetic, acetic acid and hydrogen peroxide solution) caused essential (p < 0.001) and, in course of further reuses, deepening of lowering of intradialytic leukopenia and neutropenia as well as the activation of the complement system already at the second reuse. At the same time at the second and fourth reuse of dialyzers reutilized with Dialina the activation of the complement system was essentially lower than reutilized with the other liquids (p < 0.02). At the fourth reuse intradialytic thrombocytopenia also lowered essentially (p < 0.01). Creatinine clearance lo

Topics: Acetates; Acetic Acid; Adolescent; Adult; Biocompatible Materials; Cellulose; Creatinine; Female; Formaldehyde; Hemodialysis Solutions; Humans; Hydrogen Peroxide; Kidney Failure, Chronic; Male; Membranes, Artificial; Middle Aged; Renal Dialysis; Sodium Hypochlorite; Time Factors

Disadvantages of continuous ambulatory peritoneal dialysis (CAPD), such as inconvenience and bulkiness of the apparatus, inflexibility of infusion volume, and predictable peritonitis incidence may be altered by using systems which allow disconnection from the tubing and bag after each exchange. At University of Michigan we have followed 35 patients using the O set with sodium hypochlorite (Baxter Healthcare Corp.) for 15.5 +/- 10 months, 16 patients using the Y configuration Ultraset (Baxter Healthcare Corp.) for 8.1 +/- 5 months, and 6 patients using a universal adapter (Delmed Corp.) for 14.3 +/- 7 months. Failure occurred in 7 cases (18%) at 12 +/- 8 months using the O set (3 elective, 3 related to peritonitis, 1 ultrafiltration difficulty), and 1 (7%) at 3 months using the Ultraset (related to peritonitis). Accidental sodium hypochlorite infusion occurred 8 times in 6 patients, 4 patients still on CAPD without residual effect and 2 in whom infusion contributed to failure but not to ultrafiltration difficulty. Cumulative per-patient-year (episode/months) peritonitis rates of 0.75 (1/16.4), 0.65 (1/18.4) and 0.88 (1/14.3), respectively, compare favorably with the overall center experience of 0.96 (1/12.2) (NIH-CAPD Registry). Peritonitis rates did not differ during use of any of the disconnect systems between patients with prior CAPD experience compared to patients without prior CAPD experience.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Adult; Bacterial Infections; Catheters, Indwelling; Evaluation Studies as Topic; Female; Humans; Kidney Failure, Chronic; Male; Peritoneal Dialysis, Continuous Ambulatory; Peritonitis; Retrospective Studies; Sodium Hypochlorite

Patients receiving hemodialysis therapy risk exposure to both disinfectants and sterilants. Dialysis equipment is disinfected periodically with strong solutions of hypochlorite or formaldehyde. More recently, reuse of dialyzers has introduced the use of additional sterilants, such as hydrogen peroxide and peracetic acid. The use of these sterilants is recognized by the center staffs and the home patient as a potential risk, and residue tests are carried out for the presence of these sterilants at the ppm level. Gross hemolysis resulting from accidental hypochlorite infusion has led to cardiac arrest, probably as a result of hyperkalemia. Formaldehyde is commonly used in 4% solutions to sterilize the fluid paths of dialysis controllers and to sterilize dialyzers before reuse. It can react with red cell antigenic surfaces leading to the formation of anti-N antibodies. Such reactions probably do not occur with hypochlorite or chloramines. The major exposure risk is the low concentration of disinfectant found in municipal water used to prepare 450 L dialysate weekly. With thrice-weekly treatment schedules, the quality requirements for water used to make this solution must be met rigorously. Standards for water used in the preparation of dialysate have recently been proposed but not all patients are treated with dialysate meeting such standards. The introduction of sterilants via tap water is insidious and has led to more pervasive consequences. Both chlorine and chloramines, at concentrations found in potable water, are strong oxidants that cause extensive protein denaturation and hemolysis. Oxidation of the Fe2+ in hemoglobin to Fe3+ forms methemoglobin, which is incapable of carrying either O2 or CO2.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Chloramines; Disinfectants; Formaldehyde; Humans; Kidney Failure, Chronic; Peroxides; Renal Dialysis; Sodium Hypochlorite; Water Supply

As part of a study to evaluate the safety and efficacy of dialyzer reuse, a comparative study of two methods of dialyzer reprocessing, manual and automated, was conducted. Five stable end-stage renal disease patients on center hemodialysis were evaluated as to hematological and metabolic parameters throughout two series of three consecutive dialyses using first new and then reused dialyzers reprocessed according to each of the two methods. New dialyzers and reused dialyzers following automated reprocessing always induced a profound fall in circulating neutrophil counts shortly after the start of dialysis. Hemodialysis neutropenia was not observed, however, with reused dialyzers reprocessed manually unless the concentration of sodium hypochlorite (bleach) employed was made equal to that required in automated reprocessing by being raised from 1.0 to 4.3%. It would be reasonable to conclude from these results that among the various differences between the two dialyzer reprocessing methods, restoration of the original level of biocompatibility of the reused dialyzer's membrane is related to the concentration of the cleansing agent.

Topics: Adult; Agranulocytosis; Blood Cell Count; Detergents; Female; Humans; Kidney Failure, Chronic; Male; Membranes, Artificial; Middle Aged; Neutropenia; Renal Dialysis; Sodium Hypochlorite; Surface-Active Agents

Topics: Cellulose; Female; Humans; Kidney Failure, Chronic; Kidneys, Artificial; Leukocyte Count; Leukopenia; Male; Membranes, Artificial; Sodium Hypochlorite

A case of accidental exposure of a patient undergoing hemodialysis to a sodium hypochlorite solution is reported. A 61-year-old woman was completing a hemodialysis treatment when routine cleaning of the hemodialysis machine was started. Approximately two liters of undiluted sodium hypochlorite cleaning solution (Chlorox) was added to the dialysis bath, soaking the membrane fibers. For less than two minutes the Chlorox-soaked membrane was in contact with the blood returning to the patient. This accident led to massive hemolysis, hyperkalemia, cyanosis, and cardiopulmonary arrest. Hemolysis may have been caused by the hypertonic solution, rapid exothermic protein degradation, alkaline degradation, or another mechanism. The sudden rise and fall in the concentrations of serum electrolytes and subsequent hyperkalemia was the most probable cause for the cardiac arrest. Cardiopulmonary resuscitation was started, the patient was intubated, given oxygen, sodium bicarbonate, atropine, dopamine, and isoproterenol. Sodium thiosulfate 5 g was administered by a nasogastric tube approximately 25 minutes after the cardiac arrest as a neutralizing reducing agent. The patient's condition stabilized, and she recovered after a week of hospitalization. Cleaning solutions used in the routine cleaning of hemodialysis machinery represent potentially toxic agents. Hemodialysis procedures should ensure that cleaning and sterilizing solutions cannot accidentally come into contact with a dialysis machine that is still connected to the patient.

Topics: Electrolytes; Female; Humans; Kidney Failure, Chronic; Kidneys, Artificial; Middle Aged; Renal Dialysis; Sodium Hypochlorite