It’s ultrapure, or nothing else.

We have heard that message overseas for many years: dialysis programs there have higher standards for water quality than in the U.S. Use of ultrapure water has been tied to a reduction in inflammatory factors for patients with kidney disease.

“For improved patient outcomes, the ultimate goal is to eventually transition to the use of ultrapure fluids as the technology improves and to move toward a common evidence-based standard that is accepted internationally,” noted Coulliette et al. in the paper, “Hemodialysis and water quality.” 1

While U.S. dialysis providers say achieving ultrapure water is expensive, one Canadian program that cares for pediatric patients has made the investment and sees the rewards as part of a new hemodiafiltration clinic. In fact, the Dialysis and Apheresis team at The Hospital for Sick Children in Toronto (SickKids)  is the first in North America to use HDF for pediatric care.

Read also: Water treatment: The largest syringe used in dialysis 

To achieve the water quality that HDF requires, the dialysis program uses Mar Cor’s Biopure HX2, a double pass reverse-osmosis water treatment system that is used in combination with endotoxin filtration. Mar Cor worked with SickKids’s technical staff to test the system for the HDF program and found that it achieved endotoxin levels that exceeded the Product Water Acceptance Criteria CAN/ CSA-ISO13959-11 and CAN/CSA-ISO11663-11 for ultrapure water, “This makes the system uniquely suited for use in hemodiafiltration as ultrapure dialysate is required,” notes Chris Fournier, vice president of marketing for Mar Cor. “The ultrapure requirement is <0.03 IU/ml for endotoxin levels. The Biopure HX2 tested at 0.01 IU/ml. It is our standard product, used in Canada and other countries outside the US.”

Christoph Licht, MD, the Medical Director of Nephrology at SickKids, says HDF provides better clearance during dialysis. That’s particularly important for pediatric patients, because inadequate therapy can lead to adverse developmental side-effects, including impaired cognitive development and growth, anemia, and reliance on medication. “The more toxins we can clear from the blood, the better outcomes we will have for our patients,” said Licht.

Hemodiafiltration works by infusing ultrapure dialysate fluid directly into the patient’s blood stream. This process removes more toxins than other forms of dialysis, helping to reduce the inflammatory response that usually leads to the negative side-effects seen during dialysis.

“We have found that patients have more energy, live with fewer diet and fluid restrictions, and have closer to normal development,” says Licht, who first looked at outcomes for hemodiafiltration overseas before starting the SickKids program. Licht’s team is now doing research to compare patient outcomes after transitioning from hemodialysis to hemodiafiltration.

SickKids has a history of pioneering new dialysis treatments, establishing nocturnal home hemodialysis and among the first wave of hospitals worldwide to implement peritoneal dialysis for children.


Coulliette A, Arduino M. Hemodialysis and water quality. Semin Dial. 2013 Jul-Aug; 26(4): 427–438