Endotoxin is one of the most important bacterial components contributing to the inflammatory process. Levels of endotoxin correlate directly with severity of meningococcal disease and other forms of sepsis, and with elaboration and release of inflammatory mediators. Endotoxin upregulates TNF-α, IL-1 and IL-6, complement and coagulation pathways.
Conventional dialysis requires the endotoxin concentration in the dialysis water and dialysate to be <2 EU/ml with an action level of 1 EU/ml. However, the 2011 AAMI recommendations lowered the acceptable endotoxin concentration to <0.25 EU/ml in dialysis water and <0.5 EU/ml in the dialysate
Follow-up on Sample Results
If the microbiology count/endotoxin concentration is lower than the action threshold, resume routine testing of dialysis water the following month.
Action threshold: microbiology count >50 CFU/mL; endotoxin: >0.125 EU/ mL.
If the microbiology count/endotoxin concentration exceeds the action threshold, take corrective action.
• If this is the 1st result to exceed the action threshold, retake sample as soon as possible
If this is the 2nd result to exceed the action threshold, contact person responsible for dialysis water quality assurance (e.g., biomed, renal tech, nursing unit), if not already notified, to perform the next steps as per flowchart on Table 1
If this is the 3rd (or more) result to exceed the action threshold, it is likely that biofilm is present in the water treatment and must be removed. Contact the water treatment system vendor for guidance. Retest the system or portable RO.
