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Dialysate purity has become a major concern in recent years since it was shown that low levels of endotoxin in dialysate were able to induce the production of proinflammatory cytokines, which were putatively implicated in the development of dialysis-related pathology. On-line haemodiafiltration (HDF; or haemofiltration) using the dialysate as the source of substitution fluid magnifies this risk and reinforces the critical role of the dialysate quality to be used. In order to virtually abolish the risk related to dialysate contaminants, it is mandatory to ensure the highest purity of the dialysate used in order that the substitution fluid produced satisfies the quality demands of a sterile and pyrogen-free infusion solution. Ultrapure dialysate production is therefore a common need for all on-line systems where substitution fluid is prepared continuously by sterilizing filtration of the dialysate. However, since dialysate purity plays a role in the complex haemocompatibility interaction which occurs during the haemodialysis session, the use of ultrapure dialysate must be considered as a suitable option for all haemodialysis modalities. To achieve this goal, one must keep in mind that ultrapure dialysate and infusate result from a complex chain of production where ultrapurity and/or sterility of the final solution relies on the weakest or worst component of the chain. Reliable production of ultrapure dialysate and infusate relies on several prerequisites: use of ultrapure water, use of clean electrolytic concentrates, implementation of ultrafilters on specifically designed HDF machines, microbiological monitoring of the chain with adequate and sensitive methods, and hygienic handling of the chain including frequent disinfection to reduce the level of contamination and to prevent biofilm formation. When properly done, the safety and reliability of on-line systems have been confirmed in large clinical studies. It is now time to validate the on-line process in large controlled clinical trials.

Microbiological purity of dialysate for on‐line substitution fluid preparation