Martin S. Favero

National surveillance of hemodialysis associated diseases in the United States, 1990

To determine trends in several hemodialysis associated diseases and practices, the Centers for Disease Control (CDC), in collaboration with the Health Care Financing Administration (HCFA), performed a mail survey of chronic hemodialysis centers in the United States in 1990. Of 1,995 centers surveyed, 1,882 (94%) representing 140,608 patients and 36,907 staff members responded. As in recent years, the 1990 survey found that certain hemodialysis practices are increasing in frequency, including treatment of water with reverse osmosis and deionizer units; use of bicarbonate dialysate and high-flux dialysis; and reuse of disposable dialyzers (in 1990, 70% of centers reused dialyzers). Hepatitis B surface antigen (HBsAg) was present at low frequency in patients (incidence, 0.2%; prevalence, 1.2%) and staff (incidence, 0.04%; prevalence, 0.3%). Antibody to hepatitis B surface antigen was present in 20% of patients and 58% of staff, and was significantly related to levels of hepatitis B vaccine coverage. Pyrogenic reactions in the absence of septicemia were reported by 20% of centers and were associated with use of high-flux dialyzer membranes and reuse of dialyzers (particularly in centers where the maximum number of reuses was 40 or more). Septicemia among hemodialysis patients was reported by 49% of centers. Twenty-six percent of centers reported providing hemodialysis for patients infected with human immunodeficiency virus (HIV), and 1.1% of dialyzed patients had known HIV infection.

National surveillance of dialysis associated diseases in the United States, 1992

To determine trends in a number of hemodialysis associated diseases and practices, the Centers for Disease Control and Prevention, in collaboration with the Health Care Financing Administration, completed a mail survey of chronic hemodialysis centers in the United States in 1992. Of 2,321 centers surveyed, 2,170 (93%) representing 170,028 patients and 43,535 staff members responded. In 1992, 2,049 (94%) centers used bicarbonate dialysate as the primary method of dialysis, 765 (35)% used high flux dialysis, and 1,569 (72%) reused dialyzers, continuing the trends toward increased use of these methods. Central (subclavian or jugular) venous catheters were used in > or = 1 patient as permanent vascular access for hemodialysis at 69% of dialysis centers. Hepatitis B surface antigen was present at low frequency in patients (incidence = 0.1%, prevalence = 1.2%) and staff members (incidence - 0.03%, prevalence = 0.3%). Among centers that had > or = 1 hepatitis B surface antigen positive patient, the incidence of hepatitis B virus infection was lower in those centers that used a separate room for dialysis of patients positive for hepatitis B surface antigen. From 1991 to 1992, reported hepatitis B vaccine coverage increased from 17% to 24% among patients and from 56% to 69% among staff members; in absolute terms, these were the largest single year increases since introduction of hepatitis B vaccine. The prevalence of antibody to hepatitis C virus was 8.1% among patients and 1.6% among staff members. Pyrogenic reactions in the absence of septicemia were reported by 19% of centers and associated with use of high flux dialysis. New dialyzer syndrome was reported by 24% of centers, most frequently by centers using regenerated cellulose or cuprophan membranes. Human immunodeficiency virus was known to be present in 1.5% of patients; 34% of centers reported providing hemodialysis to one or more patients infected with HIV.

National surveillance of dialysis associated diseases in the United states-1994

Dialysis centers in the United States were surveyed in 1994 regarding a number of hemodialysis associated diseases and practices. A total of 2,449 centers, representing 206,884 patients and 50,314 staff members, responded. In 1994, 99% of centers used bicarbonate dialysate as the primary method of dialysis, 45% used high flux dialysis, and 75% reused dialyzers. Hepatitis B vaccine had been administered to 31% of patients and to 80% of staff members. Acute infection with hepatitis B virus occurred in 0.1% of patients and was more likely to be reported by centers with lower proportions of patients vaccinated against hepatitis B virus and those not using a separate room and dialysis machine to treat hepatitis B surface antigen positive patients. The prevalence of antibody to hepatitis C virus was 10.5% among patients and 1.9% among staff members and varied according to geographic region. Pyrogenic reactions in the absence of septicemia were reported by 22% of centers and were most highly associated with dialyzer reuse. Human immunodeficiency virus infection was reported to be present in 1.5% of patients; 37% of centers provided hemodialysis to one or more patients infected with human immunodeficiency virus.

National surveillance of dialysis associated diseases in the United States, 1991.

To determine trends in a number of hemodialysis associated diseases and practices, the Centers for Disease Control and Prevention in collaboration with the Health Care Financing Administration performed a mail survey of chronic hemodialysis centers in the United States in 1991. Of 2,123 centers surveyed, 2,046 (96%), representing 155,877 patients and 40,298 staff members, responded. The 1991 survey found that certain hemodialysis practices are increasing in frequency, including use of bicarbonate dialysate and high-flux dialysis and reuse of disposable dialyzers (in 1991, 71% of centers reused dialyzers). Hepatitis B surface antigen (HBsAg) was present at low frequency in patients (incidence = 0.2%, prevalence = 1.3%) and staff (incidence = 0.04%, prevalence = 0.3%). Among centers that had > or = HBsAg positive patient, the incidence of hepatitis B virus (HBV) infection was lower in those centers that used a separate room for dialysis of HBsAg positive patients. Reuse of dialyzers, blood lines, transducer filters, or dialyzer caps was not associated with an increased risk of acquiring HBV infection among either patients or staff. Antibody to HBsAg was present in 21% of patients and 53% of staff, and was significantly related to levels of hepatitis B vaccine coverage. Pyrogenic reactions in the absence of septicemia were reported by 20% of centers and associated with the reuse of dialyzers. Human immunodeficiency virus (HIV) was known to be present in 1.2% of patients; 29% of centers reported providing hemodialysis to one or more HIV infected patients.

National surveillance of dialysis associated diseases in the United States, 1993

To determine trends in a number of hemodialysis associated diseases and practices, the Centers for Disease Control and Prevention, in collaboration with the Health Care Financing Administration, performed a mail survey of 2,304 chronic hemodialysis centers in the United States in 1993. By the end of 1993, at least three doses of hepatitis B vaccine were administered to 29% of patients and 76% of staff at responding centers. Hepatitis B surface antigen was present at low frequency in patients (incidence = 0.1%, prevalence = 1.2%) and staff members (incidence = 0.2%, prevalence = 0.3%). The 1993 incidence of hepatitis B virus infection among patients was higher at centers that accepted hepatitis B surface antigen positive patients but did not use a separate room and dialysis machine for treatment of these patients, government and profit (versus nonprofit) centers, and centers in four End Stage Renal Disease Networks. The prevalence of antibody to hepatitis C virus was 9.7% among patients and 1.6% among staff members. Pyrogenic reactions in the absence of septicemia were reported by 21% of centers and associated with use of high flux dialysis. Human immunodeficiency virus infection was known to be present in 1.5% of patients; 34% of centers reported providing hemodialysis to one or more human immunodeficiency virus infected patients.

In vivo studies of dialysis-related endotoxemia and bacteremia

The transfer of bacteria and endotoxin and the development of fever was monitored during hemodialysis of dogs. Bacterial and endotoxin levels in dialysis fluids exceeded those reportedly associated with pyrogenic reactions, and bacteria-free dialysate filtrates administered intravenously were shown to be pyrogenic in 2 of 2 dogs. During 18 hollow-fiber dialyses, neither bacteria nor endotoxin, as measured in the Limulus lysate assay (LLA), was detected in venous and arterial blood samples. Body temperatures did not increase during or within 1/2 h after dialysis. In experiments with parallel dialyzers, contaminated dialysate was simultaneously ultrafiltered into the second blood compartment. Ultrafiltrates were unreactive in the LLA and the absence of pyrogens was confirmed with the pyrogen test, USP, in five of five experiments. This investigation suggests that the intact cellophane membrane of the hollow-fiber dialyzer is an effective barrier to endotoxin and bacteria.

Microbiologic Principles Applied to Reprocessing Hemodialyzers

This chapter discusses important microbiologic considerations of dialyzer reuse. The terms sterilization and disinfection are defined especially in the context of dialyzer reuse, and microbiologic guidelines are described that are applied to water used to prepare dialysis fluid in contradistinction to water employed for rinsing dialyzers and preparing chemical germicide solutions in dialyzer reuse programs. Guidelines pertaining to bacterial endotoxin and chemicals in waters also are discussed.