Comparison of techniques for culture of dialysis water and fluid

Introduction: Microbiological culture of dialysis water and fluid is a routine safety measure. In the United States (U.S.), laboratories perform these cultures on trypticase soy agar at 35–37°C for 48 h (TSA‐48h), not on the tryptone glucose extract agar or Reasoner's 2A agar at 17–23°C for 7 days (TGEA‐7d and R2A‐7d, respectively) recommended by international standards. We compared culture methods to identify samples exceeding the accepted action level of 50 CFU/mL. Methods: Dialysis water and fluid samples collected from 41 U.S. dialysis programs between 2011 and 2014 were cultured at two U.S. laboratories. Each sample was cultured using (1) either TGEA‐7d or R2A‐7d and (2) TSA‐48h. We compared proportions exceeding the action level by different methods and test characteristics of TSA‐48h to those of TGEA‐7d and R2A‐7d. Findings: The proportion of water samples yielding colony counts ≥50 CFU/mL by TGEA‐7d was significantly different from the proportion by TSA‐48h (P = 0.001; difference in proportion 4.3% [95%CI 1.3–7.3%]). The proportions of dialysis fluid samples ≥50 CFU/mL by TGEA‐7d and TSA‐48h were not significantly different; there were no significant differences for comparisons of R2A‐7d to TSA‐48h. Discussion: In dialysis fluid, TSA‐48h was comparable to TGEA‐7d and R2A‐7d in identifying samples as having bacterial counts ≥50 CFU/mL. In dialysis water, TSA‐48h was comparable to R2A‐7d in identifying samples ≥50 CFU/mL, but TGEA‐7d did yield significantly more results above 50 CFU/mL. Nonetheless, the negative predictive value of a TSA‐48h result of <50 CFU/mL in dialysis water exceeded 95%.     

Ultrapure dialysis fluid: Improving conventional and daily dialysis

Dialysis fluid of standard quality contains a certain amount of bacteria and endotoxin. This has been considered acceptable because the dialysis membrane was believed to be a protective barrier to blood. However, improved methods for detection of cellular activation have demonstrated that bacterial products in the dialysate may stimulate monocytes to produce cytokines with most dialysis membranes. Ultrapure dialysis fluid is practically free from bacteria and endotoxin (< 0.1 CFU/mL and < 0.03 EU/mL) and can be prepared from standard‐quality dialysis fluid using a single step of controlled ultrafiltration. The European guidelines for hemodialysis (HD) set the use of ultrapure dialysis fluid as the goal for all dialysis modalities. Several clinical studies report improved inflammatory status in HD patients when ultrapure dialysis fluid is used, compared with standard‐quality dialysate. The benefits include less frequent occurrence of carpal tunnel syndrome, lower C‐reactive protein values, reduced need for erythropoietin, better nutritional status, and even better preservation of residual renal function. For patients on daily dialysis, dialysate quality is especially important because such patients are often treated at home where quality control of incoming water may be less rigorous, and increased treatment frequency leads to exposure to larger volumes of dialysis fluid than with conventional dialysis. The use of ultrapure dialysis fluid together with low‐complement‐activating membranes maximizes the biocompatibility of a dialysis treatment, a goal of treatment, although there is a lack of evidence to date supporting a beneficial effect on mortality. From a physiologic point of view the reduced inflammatory stimulus that can be achieved with ultrapure dialysis fluid is highly desirable. In addition, achieving ultrapure dialysis fluid is realistic, because today it can be practically and economically prepared using modern equipment and applying appropriate microbiologic surveillance techniques.     

Microbial quality of hemodialysis water,a survey of six centers in Lagos,Nigeria

Patients with end‐stage kidney disease (ESRD) on maintenance hemodialysis (HD) are usually exposed to large volumes of dialysate, which is separated from patients' blood only by thin membrane of dialyzer. It is therefore essential to frequently monitor the quality of HD water to ensure that it meets the recommended standards. The objective of this study was to evaluate the microbial quality of HD water in Lagos, Nigeria. Four sets of pre‐ and post‐treatment water samples, 20 mL each, were collected from six HD centers in Lagos and tested for microbial contamination using the molten Tryptic soy agar in accordance with Association for Advancement of Medical Instrumentation (AAMI) and European Best Practice Guidelines (EBPG). Pyrogen tests were also conducted on pre‐ and post‐treatment samples using standard technique. Information on water treatment modalities, maintenance practices and quality control measures in each center were obtained using a questionnaire. All centers use treated water for HD purpose. None of the HD centers met EBPG/AAMI guidelines for microbial contaminants as the mean levels of Escherichia coli in both feed and treated water were 441.7 ± 87.90 and 168.5 ± 64.03, respectively. E. coli was the commonest organism isolated in both feed and treated water in all the centers. HD water quality is still a neglected problem in our environment and more efforts are required to ensure good water quality for HD purpose.     

Clinical benefits of ultrapure dialysis fluid for hemodialysis

Ultrapure dialysis fluid contains less than 0.1 CFU/mL and 0.03 EU/mL and can be prepared by ultrafiltration of standard‐quality dialysis fluid. Today, the use of ultrapure dialysis fluid is widely recommended based on our awareness of potential transfer of bacterial products across dialysis membranes. Early observations associated improved fluid quality with reduced incidence of the carpal tunnel syndrome, but provided no proof of mechanism. Recent clinical studies in hemodialysis patients have shown that the introduction of ultrapure dialysis fluid brings about significant improvements in a number of inflammation‐related parameters. Levels of C‐reactive protein and IL‐6 are reduced, anemia management is achieved using less EPO or reaching higher hemoglobin levels, nutritional indices are improved, and β₂‐microglobulin levels have been observed to decline, when ultrapure dialysis fluid is used in comparison with standard‐quality fluid. In addition, some studies have documented reduced levels of advanced glycation end products and delayed decline of residual renal function in patients using ultrapure dialysis fluid. Although further evidence is needed before we can assess the long‐term benefits associated with improved fluid quality, there should be sufficient data available today to support our efforts toward gradual improvement of the microbiological quality of dialysis fluid.     

Quality of hemodialysis water in a resource‐poor country: The Nigerian example

Hemodialysis (HD) patients are exposed to large volumes of water, separated from patients' blood by semipermeable membrane of dialyzers. Chemical contaminants in poorly treated water impact negatively on quality of life of these patients. This survey was carried out to assess the HD water quality in Lagos, Nigeria. Ten milliliters of feed and treated water from all six HD centers in Lagos were tested for aluminum, copper, zinc, magnesium, calcium using atomic absorption spectrometry; sodium and potassium were tested using flame photometry, fluoride with molecular photoluminescence method; sulfate using turbidimetry, nitrates measured by cadmium column reduction method, chloramines and free chlorine were measured using N, N‐diethyl‐1‐P‐phenylenediamine colorimetric method. Information on sources of feed water, frequency of testing of HD water, methods of water treatment, type of water purification system and maintenance was also obtained. All centers used borehole as main source of water supply. None of the centers met Association for the Advancement of Medical Instrumentation (AAMI) guidelines for most chemical contaminants. Only chlorine (0.48 ± 0.07 mg/L) and potassium (3.9 ± 0.95 mg/L) levels met AAMI standards after treatment. Mean levels of chemical contaminants in treated water were as follows: aluminum 0.04 ± 0.01 mg/L, zinc 0.27 ± 0.08 mg/L, chloramines 0.16 ± 0.03 mg/L, fluoride 1.83 ± 0.40 mg/L, sulfate 117 ± 86.1 mg/L which were mildly elevated; calcium 126.00 ± 22.7 mg/L, sodium 179 ± 25.6 mg/L, and nitrate 70.5 ± 50.8 mg/L, which were markedly elevated; and magnesium 8.3 ± 3.38 mg/L, which was moderately elevated above AAMI recommended levels. HD water quality is poor in our environment. Concerted efforts are required to ensure good quality water for HD.     

Real-time potentiometric detection of bacteria in complex samples

Detecting and identifying pathogen bacteria is essential to ensure quality at all stages of the food chain and to diagnose and control microbial infections. Traditional detection methods, including those based on cell culturing, are tedious and time-consuming, and their further application in real samples generally implies more complex pretreatment steps. Even though state-of-the-art techniques for detecting microorganisms enable the quantification of very low concentrations of bacteria, to date it has been difficult to obtain successful results in real samples in a simple, reliable, and rapid manner. In this Article, we demonstrate that the label-free detection and identification of living bacteria in real samples can be carried out in a couple of minutes and in a direct, simple, and selective way at concentration levels as low as 6 colony forming units/mL (CFU) in complex matrices such as milk or 26 CFU/mL in apple juice where the pretreatment step of samples is extremely easy. We chose Escherichia coli ( E. coli ) CECT 675 cells as a model organism as a nonpathogenic surrogate for pathogenic E. coli O157:H7 to test the effectiveness of a potentiometric aptamer-based biosensor. This biosensor uses single-walled carbon nanotubes (SWCNT) as excellent ion-to-electron transducers and covalently immobilized aptamers as biorecognition elements. The selective aptamer-target interaction significantly changes the electrical potential, thus allowing for both interspecies and interstrain selectivity and enabling the direct detection of the target. This technique is therefore a powerful tool for the immediate identification and detection of microorganisms. We demonstrate the highly selective detection of living bacteria with an immediate linear response of up to 10(4) CFU/mL. The biosensor can be easily built and used, is regenerated without difficulty, and can be used at least five times with no loss in the minimum amount of detected bacteria.     

Provision and quality of dialysis services in Libya

Dialysis is entirely funded by the public health care sector in Libya. Access to treatment is unrestricted for citizens but there is a lack of local information and no renal registry to gather national data. This cross-sectional study aimed to investigate dialysis provision and practice in Libyan dialysis facilities in 2009. A structured interview regarding dialysis capacity, staffing and methods of assessment of dialysis patients, and infection control measures was conducted with the medical directors of all 40 dialysis centers and 28 centers were visited. A total of 2417 adult patients were receiving maintenance dialysis in 40 centers, giving a population prevalence of approximately 624 per million. Most dialysis units were located in the northern part of the country and only 12.5% were free-standing units. Only three centers offered peritoneal dialysis. One hundred ninety-two hemodialysis rooms hosted 713 functioning hemodialysis stations, giving a ratio of one machine to 3.4 patients. Around half of centers operated only two dialysis shifts per day. Nephrologist/internist to patient ratio was 1:40 and nurse to patient ratio was 1:3.7. We found a wide variation in monitoring of dialysis patients, with dialysis adequacy assessed only in a minority. Separate rooms were allocated for chronic viral infection seropositive patients in 92.5% of the units. In general, the provision of dialysis is adequate but several areas for improvement have been identified, including a need for implementation of guidelines, recruitment of more nephrologists, and the development of more cost-effective alternatives such as peritoneal dialysis and transplantation.     

Acute hemodialysis complications in end‐stage renal disease patients: The burden and implications for the under‐resourced Sub‐Saharan African health systems

Little is known about the challenges of routine renal replacement therapy in Sub‐Saharan Africa. We investigated the fatal and nonfatal acute hemodialysis (HD) complications in patients with end‐stage renal disease (ESRD) in two main dialysis centers in Cameroon. 1000 consecutive HD sessions incurred over a 4‐month period by 129 patients (96 men, 74%) with ESRD, receiving two weekly HD sessions of 4 hours each, were considered. Personal and clinical profiles before, during, and within 24 hours after HD sessions were used to diagnose complications. Participants were aged 7 to 80 years (mean 46 years). In all, 452 acute complications were recorded in 411 (41%) of the 1000 HD sessions. Of the 11 types of complications, hypotension (25%), muscular cramps (22%), hypertensive crisis (14%), pruritus (10%), and fever (7%) were the most frequent. Three hundred and six complications (67.7%) occurred during understaffed nighttime. The vascular access was the main bleeding site with 64%. Being diabetic and ultrafiltration rate >1000 mL/h were associated with hypotension and muscle cramps. The shorter duration in dialysis was associated with the risk of bleeding and the disequilibrium syndrome while longer duration was associated with muscle cramps. Four deaths (three from bleeding and one from disequilibrium syndrome) occurred, all during nighttime. Nearly half of dialysis sessions in these settings are associated with acute complications, some of which are fatal. Those complications occurred mostly during understaffed periods. Urgent strategies are needed to quickly solve the human capital crisis in the health care sector.     

Endotoxins and inflammation in hemodialysis patients

Long‐term endotoxin challenge may promote frequent complications in dialysis patients, namely malnutrition, chronic inflammation, and atherosclerosis, which are recognized as the so‐called MIA syndrome. Circulating soluble vascular cell adhesion molecule‐1 (sVCAM‐1) levels may be used to determine the stage of atherosclerosis. This study aimed to assess endotoxin level in hemodialysis (HD) patients and its role in inducing inflammation. The study was conducted on 50 HD patients, chosen from four dialysis centers in Alexandria. Serum blood samples were collected for the determination of albumin and C‐reactive protein (CRP), and whole blood samples were used for the measurement of hemoglobin level. A heparinized whole blood sample was taken postdialysis for endotoxin assay by limulus amebocyte lysate test, and in addition to sVCAM‐1 was estimated using enzyme‐linked immunosorbent assay. The mean endotoxin level was 76.30 pg/mL;80% exhibited values higher than 60 pg/mL. Half the studied patients had CRP values that exceeded the upper limit of the laboratory reference range (<6.0 mg/L). A statistically significant correlation was found between endotoxin and CRP levels (r = 0.47, P = 0.001). The mean pre‐HD level of VCAM was 1851.00 ng/mL, while the mean post‐HD level was 2829.00 ng/mL with statistically significant correlation (r = 0.354, P = 0.012) and it also correlated significantly with endotoxin as well as CRP levels. Endotoxemia may play an important role in the aggravation of endothelial dysfunction in HD patients as indicated by the post‐HD rise in sVCAM‐1.     

The integrated management for renal replacement therapy in Portugal

Portugal was the first European country to introduce an integrated management of end‐stage renal disease (IM ESRD). This new program integrates various dialysis services and products, which are reimbursed at a fixed rate/patient/week called “comprehensive price payment.” This initiative restructured the delivery of dialysis services, the monitoring of outcomes, and the funding of renal replacement therapy. This article described the implementation of a new model of comprehensive provision of hemodialysis (HD) services and aimed to assess its impact on dialysis care. Quality assessments and reports of patient satisfaction, produced by the Ministry of Health since 2008, as well as national registries and reports, provided the data for this review. Indicators of HD services in all continental facilities show positive results that have successively improved along the period of 2009–2011, in spite of an average annual growth of 3% of the population under HD treatment. Mortality rates for HD patients were 12.7%, 12%, and 11%, respectively in 2009, 2010, and 2011; annual hospitalization rates were 4.9%, 3.8%, and 4.4% for the same years; key performance indicators showed averages above the reference values such as hemoglobin, serum phosphorus, eKt/V, water quality, number of days of hospitalization per patient per year, and number of weekly dialysis sessions. The financing analysis of IM ESRD demonstrates a sustained control of global costs, without compromising quality. The IM ERSD program is an innovative and quality‐driven approach that benefits both dialysis patients and providers, contributing toward the rationalization of service provision and the efficient use of resources.     

Determinants of survival in patients receiving dialysis in Libya

Maintenance dialysis is associated with reduced survival when compared with the general population. In Libya, information about outcomes on dialysis is scarce. This study, therefore, aimed to provide the first comprehensive analysis of survival in Libyan dialysis patients. This prospective multicenter study included all patients in Libya who had been receiving dialysis for >90 days in June 2009. Sociodemographic and clinical data were collected upon enrolment and survival status after 1 year was determined. Two thousand two hundred seventy‐three patients in 38 dialysis centers were followed up for 1 year. The majority were receiving hemodialysis (98.8%). Sixty‐seven patients were censored due to renal transplantation, and 46 patients were lost to follow‐up. Thus, 2159 patients were followed up for 1 year. Four hundred fifty‐eight deaths occurred, (crude annual mortality rate of 21.2%). Of these, 31% were due to ischemic heart disease, 16% cerebrovascular accidents, and 16% due to infection. Annual mortality rate was 0% to 70% in different dialysis centers. Best survival was in age group 25 to 34 years. Binary logistic regression analysis identified age at onset of dialysis, physical dependency, diabetes, and predialysis urea as independent determinants of increased mortality. Patients receiving dialysis in Libya have a crude 1‐year mortality rate similar to most developed countries, but the mean age of the dialysis population is much lower, and this outcome is thus relatively poor. As in most countries, cardiovascular disease and infection were the most common causes of death. Variation in mortality rates between different centers suggests that survival could be improved by promoting standardization of best practice.     

Hepatitis B and C in dialysis units in Iran: changing the epidemiology

Hepatitis B (HBV) and C (HCV) viruses are the most important infections transmitted by the parenteral route in patients receiving maintenance dialysis. The prevalence varies markedly from country to country. The aim of this study is to review the efficacy of the strategies to reduce the incidence of these infections and the trend of results in Iran. As a routine, all hemodialysis patients in Iran have biannual blood samples for assessment of serum HBSAg, HBS Abs, and HCV Abs. The data are collected in the Ministry of Health. For statistical analysis, prevalence, and incidence were calculated. There is an increasing prevalence/incidence of end-stage renal disease (ESRD) in Iran, from 238/49.9 pmp in 2000 to 357/63.8 pmp in 2006. The prevalence of positive HBSAg and HCV Abs decreased from 3.8% and 14.4% in 1999 to 2.6% and 4.5% in 2006, respectively. Regarding the genotype distribution in Iran, no one was found with genotype 2. On the subject of decreasing HBV infection, our next strategy should be mandatory vaccination in dialysis centers and in the pre-ESRD period. Concerning HCV infection prevention, 2 approaches may be recommended: the first is decrease of duration of the hemodialysis period by possible early transplantation of suitable patients. The next is a strictly enforced isolation policy for HCV-positive patients, which may play a role in limiting HCV transmission in HD units, and universal precaution in dialysis units should be under constant close surveillance.     

Safety analysis of intermittent hemodialysis in patients with continuous flow left ventricular assist devices

Dialysis centers adopt a cautious approach when it comes to performing intermittent hemodialysis (HD) on patients with continuous flow (CF) left ventricular assist devices (LVADs) because of the potential for volume flux‐related complications and absence of pulsatile blood pressure for monitoring. Many patients have to remain hospitalized because of the inability of the dialysis centers to accept them for outpatient dialysis. In this study, the effect of HD was observed in such patients. Between June 2009 and October 2012, 139 patients received LVADs, of which 10 patients (7%) required intermittent HD postoperatively. The mean age of the patients was 53 ± 14 years and 90% were men. A total of 281 dialysis sessions were administered amounting to 1025 hours of dialysis. The mean systolic blood pressure monitored with Doppler device was 97 ± 18 mmHg. Dialysis durations averaged 218 ± 18 minutes. Mean blood flow rate was 334 ± 38 cc/min, and 2.6 ± 1.1 L was ultrafiltrated during each session. Only 15 (5.3%) sessions were interrupted or terminated in six patients. The reasons for termination were symptomatic hypotension—6 (2.1%), asymptomatic hypotension—3 (1%), ventricular tachycardia—1 (0.36%), dialysis machine malfunction—2 (0.7%), low phosphorus—2 (0.7%), and abdominal cramps—1 (0.36%). Volume expansion was necessary on three occasions. Low‐flow device alarms were registered during two (0.71%) sessions. The results showed no serious adverse effects or deaths.     

Cardiac troponin-I and its prognostic significance in a dialysis population

Background: The objective was to study the prevalence and specificity of elevated levels of cardiac troponin‐I (cT‐I) in patients on maintenance hemodialysis in relation to creatine kinase (CK), the CK‐MB fraction, and the ratio CK‐MB of total CK and to assess its significance for the long‐term prognosis in these patients, compared to other parameters known to influence the outcome. Methods: Predialysis blood samples were taken from 93 asymptomatic hemodialysis patients for cT‐I, total CK, the CK‐MB fraction, and the ratio of CK‐MB to total CK. cT‐I was measured by a microparticle enzyme immunoassay. The patients were followed for 1 year, after which baseline levels of cT‐I and age, duration of dialysis, and the presence of diabetes mellitus and ischemic heart disease were correlated by linear regression analysis with the outcome parameter all‐cause mortality. Results: None of the patients had a cT‐I level higher than the manufacturer's indicated cutoff point of 2.0 ng/mL for myocardial infarction, indicating a specificity of 100%. Nine of the 93 patients (9.7%) had detectable cT‐I levels (>0.0 ng/mL). Twelve patients died within 1 year, among which 4 had baseline cT‐I levels above 0 ng/mL. From the study variables, an elevated baseline cT‐I was found to be the only factor that significantly correlated with the outcome all‐cause mortality (p = 0.029). Conclusions: cT‐I has a high specificity for the diagnosis of myocardial infarction in dialysis patients. Despite the relatively low number of positive test results, cT‐I was found to be significantly correlated with the outcome all‐cause mortality at 1 year.     

Survival and other clinical outcomes of maintenance hemodialysis patients in Taiwan: A 5‐year multicenter follow‐up study

The increasing aging and diabetes mellitus (DM) patients in dialysis population make the quality maintenance of dialysis an imperative issue. Recently, an increasing number of dialysis centers were run by private dialysis providers, many of which apply quality assurance programs and performance management systems to dialysis care. We studied patients in dialysis facilities in Taiwan run by a private chain to see clinical outcomes of centers operating under these systemic strategies. Hemodialysis patients from January 1, 2008 to December 31, 2012 in 25 dialysis facilities in Taiwan, which received the management and consultation from a dialysis service provider, NephroCare (NC), were included. Data pivotal to quality of dialysis were analyzed. During a 5‐year interval, 5161 hemodialysis patients were included. For volume control, the proportion of patients with weight gain ≥4.5% decreases from 41.7% to 30.2%. Mean Kt/V is 1.74 ± 0.28. Mean albumin level is 3.92 ± 0.38 g/dL. Patients with phosphate <5.5 mg/dL is up to 71.8%. The mean hemoglobin level is 10.70 ± 1.40 g/dL. More than 80% of patients have adequate iron status. Further, 73% of patients use native arteriovenous fistula. Hospitalization‐free survival rate was 56% at the fifth year. Patient survival rate at the fifth year was 66.4%. Overall clinical performances were maintained very stable in NC facilities from this temporal data analysis. The hospitalization and survival rate also compare favorably with those reported internationally. These results warrant further studies to justify the application of this kind of quality assurance programs and performance management systems in dialysis care.     

Quality Evaluation of Grated Graviera Cheese Stored at 4 and 12°C using Active and Modified Atmosphere Packaging

The effect of active [oxygen absorber (OA) combined with an ethanol emitter (EE)] and modified atmosphere (100% Nitrogen) packaging in combination with a high barrier experimental polyethylene terephthalate‐silicon oxides//low density polyethelene film on shelf‐life extension of grated Graviera cheese stored at 4 and 12°C was investigated. Microbiological (total viable counts, Pseudomonads, lactic acid bacteria, Enterobacteriaceae and Yeasts/Moulds), physico‐chemical (pH, thiobarbituric acid and colour) and sensory (odour and taste) changes occurring in the product were monitored as a function of treatment and storage time (10 weeks). Sensory shelf‐life was approximately 1, 1.5, 4.5, 6, 9 and at least 10 weeks for control samples (12 and 4°C), for N2 packaged samples (12 and 4°C) and samples packaged with the OA + EE (12 and 4°C), respectively. At the point of sensory rejection, yeasts and moulds increased from 2.00 to 3.60 and 5.55 log CFU/g for control samples stored at 4 and 12°C, respectively. Similarly, for samples stored under nitrogen, yeasts and moulds reached 2.00 and 2.32 log CFU/g at 4 and 12°C, respectively. Yeasts and moulds in samples with the OA + EE remained below 2 log CFU/g throughout the entire storage period, irrespective of storage temperature. pH varied between 5.72 and 6.49 depending on specific treatment. Malondialdehyde absorbance ranged between 0.05 for fresh samples and 0.79 mg/kg at the time of sensory rejection of samples. Light parameters L and b decreased while parameter a increased during storage, reflecting a gradual discolouration of all samples and especially those stored at 12°C.     

Assessing the utility of testing aluminum levels in dialysis patients

Plasma aluminum (Al) is routinely tested in many dialysis patients. Aluminum exposure may lead to acute toxicity and levels in excess of ∼2.2 μmol/L (60 μg/L) should be avoided. Historically, toxicity has been caused by excessive dialyzate Al but modern reverse osmosis (RO) water should be Al free. Nevertheless, many units continue to perform routine Al levels on dialysis patients. This single‐center study retrospectively analyzed Al levels in plasma, raw water feed, and RO product between 2010 and 2013 using our database (Nephworks 6) with the aim of determining the utility of these measurements. Two thousand fifty‐eight plasma Al tests in 755 patients (61.9% male, mean age 64.7 years) were reviewed showing mean ± SD of 0.41 ± 0.30 μmol/L. One hundred eleven (5.4%) tests from 61 patients had Al levels >0.74 μmol/L and 45 (73.8%) of these patients were or had been prescribed Al hydroxide (Al(OH)₃) as a phosphate binder. Seven patients had Al concentrations >2.2 μmol/L with no source of Al identified in 1 patient. One hundred sixty‐six patients taking Al(OH)₃ (78.7% of all patients on Al(OH)₃) had levels ≤0.74 μmol/L, the odds ratio of plasma Al > 0.74 μmol/L on Al(OH)₃ was 9. The cost of plasma Al assay is $A30.60; thus, costs were $A62,974.80 over the study period. Despite RO feed water Al levels as high as 48 μmol/L, Al output from the RO was almost always undetectable (<0.1 μmol/L) with dialyzate Al levels > 2.2 μmol/L only 3 times since 2010, and never in the last 3 years. Routine unselected testing of plasma Al appears unnecessary and expensive and more selective testing in dialysis patients should be considered.