WATER TREATMENT

Dr. Marthi Atik Coline

• Patients are exsposed to 120-200 L of dialysis solution
each dialysis treatment.
• The chemical dan microbiologic purity of dialysis is
important. Any small molecular weight contaminants in
dialysis solution can enter the blood
• The purity of the water used to prepare dialysis solution
is the resposibility of dialysis facility.
• Jumlah air yang terpapar selama HD , dengan kecepatan
dialisat 500 cc / menit
• 1 Jam 500 cc x 60 menit = 30 liter
• 5 Jam HD ( 5 X 30 Liter ) = 150 liter
• 1 minggu ( 2 x 150 Liter ) = 300 liter
Definisi
• Sumber – sumber air yang ada belum tentu dapat
dikonsumsi langsung oleh manusia perlu di
olah terlebih dahulu teknologi pengolahan air (Water
Treatment / Water Filtration)
• Water Treatment (Pengolahan Air) yaitu suatu prosedur
atau metode untuk mengubah komposisi air.
Air bersih
• Kuman sedikit
• Molekul tidak mengganggu tubuh
• Ion minimal
• Antiseptik kloramin minimal
Air orang sehat
• Jumlah ± 2 liter/ hari : 15 liter/ minggu
• Lambung : asam membunuh kuman
• Hati : proses detoksifikasi
• Ginjal : zat dapat dieksresi
Water contaminants harmful to dialysis
patients.
Some subtance added to municipal water supplies for public
health reasons pose no threat to health individuals. But causes
injury to renal failure.
1. Aluminium use to remove nonfilterable suspended particles
agent causes bone disease, encepalopathy syndrome and
anemia
2. Chloramine to prevent bacterial proliferation causes
hemolytic anemia
3. Fluoride to prevent tooth decay causes severe pruritus,
nausea and fatal ventricular fibrillation
4. Copper and zinc causes hemolytic anemia
5. Bacterial and endotoxin can cause pyrogenic reaction
6. Toxins from blue-green algae produce microcystins derive
causes toxic to hemodialysis patients.
• The International organization for standardization (ISO)
has developed minimun standards for the purity of the
water used to prepare dialysis.
• Have been adopted by the A.A.M.I as national standards
for US and are also followed by regulatory organizations
in many other countries.
Water and dialysis solution quality requirement
• Pyrogenic reactions do not occur when levels of bacteria
and endotoxins in the dialysis solution are maintaned
below limits.
• Ultrapure dialysis solution.
Low level of endotoxins and endotoxin fragments in dialysis
solution may contribute to a chronic inflammatory respons
that maybe associated with long-term morbidity in dialysis
patients.
Ultrapure is characterized by bacteria level below 0.1
CFU/Ml and endotoxin level below 0.03 EU/mL
• “ultrapure” has been linked to reduce plasma levels of C-
reactive protein and interleukin-6 an improved respon of
anemia to erythropoietin therapy, better nutrition as
evidenced by increases in plasma albumin value and
higher estimated dry body weight.
• Pretreatment
 Water Softener
 Activated Carbon filter
• Proses Pemurnian Primer (Primary Purification Process)
 Reverse Osmosis
 Deionisasi
• Distribusi air yang telah dimurnikan
 PRETREATMENT

Meliputi suatu sistem katup untuk mencampur air panas dan dingin
sampai mencapai temperatur yang konstan.
Tahap ini menyiapkan air untuk proses pemurnian selanjutnya.
Koreksi pH dengan menggunakan asam hidroklorid. ( sometimes
needed to correct excessive alkalinity which can impede the ability
of carbon beds to remove chlorine and chloramine and can cause
fouling of RO mambranes by calcium and magnesium salts )
 Kontrol Waktu

Tangki Sand Water Carbon

Asal Air Filter Softener Filter Screen Filter

Pompa

Air Garam

Aliran Dialysis Sistim

Reverse Osmosis

Buang
 WATER SOFTENER

 Berisi media Ion Exchange

Resin
 Menghilangkan Calcium
(Ca++) dan Magnesium
(Mg++) dengan cara
pertukaran dengan 2 ion
Natrium (Na+).
 Berfungsi untuk
melindungi membran RO
(Calcium dan Magnesium
dapat terdeposit pada
membran RO).
• Garam berguna untuk • Kegagalan Softener dapat

mengikat Ca dan Mg, mengakibatkan

melalui rangkaian resin “Hard Water Syndrome”.

• Air kandungan “ keras “ ( air berisi  calcium )

menjadi “ halus ” • Nausea = mual

• Aliran air terus menerus • Vomiting = muntah

menyambung ke Tangki • Headache = sakit kepala

air garam • Weakness = kelemahan
 Kandungan Air
di Filter Softener
Na+
Na Na
Na+
Ca++ Na Na Ca Mg
Na
Na+
Ca++ Na Na
Na Na Mg Ca Na+
Na
Mg++ Na+
Na Na
Ca++ Na Na
Ca
Na+
Ca++ Na Na Mg Ca
Na+
Na Na Ca
Na+
Na+
Kandungan Air Na+
Perubahan Ion
( keras ) Kandungan Air
( halus )
 ACTIVATED CARBON
FILTER

Untuk menghilangkan klorin

dan kloramin.
Klorin dan kloramin tidak
dapat dibersihkan dengan RO
dan dapat merusak membran
RO.
Chlorine can combine with
organic subtance in the water
to form potentially cancer-
causing compounds.
Previously many
municipalties use chlorine to
supress bacterial proliferation
have change to chloramine.
• Because of critical need to remove chloramine and relate
organics. The water stream is run through two carbon
beds in series. The upstream “worker” and downstream
“polisher”
 Dengan tekanan yang tinggi air dipompa melalui membran semipermeabel
sehingga solut yang tidak larut akan tertahan.
 RO akan menghilangkan >95% kontaminan ion dan nonion.
 RO merupakan penghalang yang efektif terhadap virus, bakteri dan
endotoksin.
 Sistem dan mekanisme kerja mesin Reverse Osmosis ( RO ) secara
singkat dapat dijelaskan, sbb :
 Air yang akan diproses di pompakan ke unit mesin RO. Oleh pompa
tekanan tinggi yang digerakkan oleh elektro motor pada mesin RO
tersebut, air dapat masuk ke dalam membrane untuk di proses.
Rancang bangun membrane sudah dibuat sedemikian sehingga akan
keluar air yang bersih melalui saluran air bersih dan air yang kotor
melalui saluran pembuangan
• Memakai tekanan di
satu sisi membran
semipermeable
supaya air dapat lewat
• Sebagian besar zat
organik dan elektrolit
ditolak
• BM > 200 Daltons
ditolak
 Reverse
Osmosis
Membran

ALIRAN

DISERAP
dibutuhkan

90 - 99 %
ZAT TERLARUT ditolak
CLINICAL DEPT - SAP
 DEIONISASI
 Merupakan proses pengolahan air dengan pertukaran ion melalui media
ion exchange resin.
 Dapat digunakan sebagai alternatif dari RO, tetapi seringkali digunakan
sebagai kelanjutan dari RO.
 Tidak dapat menghilangkan kontaminan nonion, bakteri atau endotoksin.
 Setelah osmosis reversibel, air melewati mixed-bed resin(anion-
kation)deionizer, untuk memastikan konduktivitas cukup rendah dibanding
nilai standard yang sudah ditentukan. Desain dari deionizer sendiri
bergantung pada volume berjalannya air pada perputaran air selama 6
bulan.
Distribution of purified water
• Purified water must be distibuted to individual dialysis
machine to produce dialysis solution that remains free
contaminants.
• Chemical contaminants are avoided by using
inert materials such as plastic.
• The water distribution system is configured in a
loop withoout multiple branches or dead ends.
• Water storage and distribution systems are
disinfected on regular schedule(chemical
germicides) to prevent bacterial colonization and
minimize the formation of bio film
MASALAH PEMIPAAN (LOOP) =
SIRKULASI

T
Cabang

Sudut
Aliran Diam
LANGKAH untuk Meminimalkan
BIO FILM
• Sistem yang tepat
• Perhatikan aliran air
• Kebersihan
• Merubah aliran yang
bercabang
Regular Water Test
Importance of monitoring water quality. Water Testing :
- Chemical water testing
- Microbial water testing
- Chlorine/chloramines tests
- Water testing for endotoxins