Table 5.

Contaminants toxic to patients on dialysis

Contaminant	Source	Adverse Event	Notable
Aluminum	Municipal water treatment	Fatal encephalopathy syndrome, bone disease, anemia	Aluminum is usually included in the laboratory AAMI water quality panel of compliance tests
Calcium/magnesium	Municipal source water, municipal water treatment	Nausea, vomiting	Calcium and magnesium can scale and foul the reverse osmosis membrane, reducing membrane performance
Copper	Dialysis water treatment	Hemolysis, nausea, vomiting	Copper can leach from plumbing and fixtures in acidic conditions
Cyanotoxin	Municipal water treatment	Hepatic failure	Blue-green algal toxins should not be in the treated water; may create a pyrogenic reaction in exposed patients
Endotoxin	Dialysis water treatment	Pyrogenic reaction, chronic inflammation	Reverse osmosis and endotoxin filtering work to reduce endotoxin contamination in purified water; if endotoxin is present, however, it can pass through the dialyzer membrane into blood by backfiltration
Fluoride	Municipal water treatment	Nausea, abdominal pain, pruritus, arrhythmia	Fluoride may also be associated with uremic bone disease
Monochloramine	Municipal water treatment	Hemolysis	In addition to depleting carbon filters, chloramines can degrade some reverse osmosis membranes
Nitrates	Municipal water treatment	Anemia	Nitrates have no known effects on the function of the water treatment system
Zinc	Dialysis water treatment	Hemolysis, nausea, vomiting	Zinc oxide can interfere with carbon filter function and cation exchange in the water softener

AAMI, Association for the Advancement of Medical Instrumentation. Modified from ref. 11, with permission.