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Poster Repro

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Repro Arts in 3 minutes

Hemodialysis and toxins: is there a risk?

Health care practitioners in Canada go to great lengths to ensure
that patients receive the best care available and that any potential
risks associated with their treatment are minimized. Unfortunately, the
use of medical devices and products designed to treat illnesses may, in
fact, be placing patients in the direct line of fire for other serious
health risks (Calafat et al., 2008). Furthermore, there is also strong
evidence that suggests that health care providers and those who work in
a health care setting are equally at risk of being exposed to various
harmful elements (Wilding, Curtis, & Welker-Hood, n.d.). And what is
the overlooked danger? In a word--toxins.

For the purpose of this discussion, let us look to The
Canadian
Environmental Protection Act

 for a description of a toxic substance. The
Act defines a toxic substance as: '21 substance is toxic if it is
entering or may enter the environment in a quantity or concentration or
under conditions that: a) have or may have an immediate or long-term
harmful effect on the environment or its biological diversity; b)
constitute or may constitute a danger to the environment on which life
depends; or c) constitute or may constitute a danger in Canada to human
life or health" (Environment Canada, 2012).

By this definition, then, it is clear that when toxic chemicals
surround us, we may become toxic ourselves. Our bodies accumulate more
every day, as we come into contact with a toxic substance, usually
without our knowledge or consent. Some we absorb by inhaling the air in
buildings or cities, others as we consume foods, and during medical
procedures. The fact that there are biomonitoring programs, such as
those used by the Centers for Disease Control and Health Canada, is
proof that we should be concerned. These programs have been in use for
many years in order to determine the level of toxic burden we encounter
and whether or not these chemicals are of direct concern to human
health.

[ILLUSTRATION OMITTED]

But patients and health care workers are at particular risk. Three
recent studies all concluded that each and every one of us is affected
by hazardous chemicals. The recently published Canadian Health Measures
Survey (
CHMS

CHMS Church Management Software
CHMS Church Management System
CHMS Chapel Hill Middle School  
) results determined that within the group of 5,600
participants, 100% of the population had detectable levels of lead and
91 % of the population had detectable levels of Bisphenol-A (B PA)
(Statistics Canada, 2011). An American study conducted by the Physicians
for Social Responsibility (
PSR

) concluded that all 20 health care
professionals in their study had detectable levels of at least 24 of the
62 chemicals tested, with some having as many as 39. All participants
had detectable levels of
BPA
 British Paediatric Association.
 and nearly all had at least one
phthalate

n. 1. (Chem.) A salt of phthalic acid.
 metabolite in their blood (Wilding, Curtis, & Welker-Hood, n.d.).
Additionally, a study by Environmental Defence, a Canadian
non-government-based organization, arrived at similar conclusions
regarding our exposure to toxins.

With a growing number of chronically ill patients, the urgency to
eliminate toxic chemicals from medical devices and procedures increases.
Exposure to the growing number of environmental and medical toxins
introduces new risks to patient health. Could we see a rise in
comorbidity not present before in these groups as a result?

[ILLUSTRATION OMITTED]

One such group at risk are those suffering from
chronic kidney
disease

 (
CKD

). CKD is already quite prevalent and with an increase in
the number of Canadians suffering from high blood pressure and diabetes,
the National Research Council of Canada estimates that approximately 5%
of the Canadian population is affected by CKD. Of that number, in 2008,
the
Canadian Institute for Health Information

 reported that there were
17,762 Canadian patients who were undergoing hemodialysis therapy as
treatment for CKD. That figure is translated to approximately 2,770,880
treatments per year.

Where the concern lies with hemodialysis patients is the large
number of single-use medical devices (blood tubing, dialyzers) and the
risks associated with their use. As previously stated, we all have
toxins flowing through our veins. However, some of these chemicals and
their metabolic by-products can be relatively safely excreted through

urination

 in the healthy individual. Clearly, this is not possible for
individuals with impaired renal function. Most single-use devices for
use in hemodialysis contain one of two common chemicals, both of which
are known endocrine disruptors.

Some of these chemicals are listed on the packaging and others may
not be, leading to more confusion and risk for the end user. The
chemicals of most concern to us in hemodialysis are Phthalates and
Bisphenol-A.

Plasticizing agents known as phthalates are added to polyvinyl
chloride plastics (#3) to make them more malleable. The most common of
these phthalates used is di-2-ethylhexyl phthalate or
DEHP
phthalate
DEHP Diethylhexylphthalate
DEHP Diethyl Hydrogen Phosphite
DEHP Dual Encoding Hierarchical Pipelining
 (Environmental Working Group, 2007-2012). DEHP can be found within
commonplace items such as vinyl flooring and chair upholstery, but more
alarming are medical devices such as hemodialysis blood tubing, IV
tubing, oxygen tubing, blood and IV fluid bags, and catheters.
Ultimately, many of these products come in direct contact with a
patient's blood-stream for extended periods of time, leading to
absorption (Tickner, Schettler, Guidotti, McCally, & Rossi, 2001).

Bisphenol-A (BPA) is an industrial chemical used as a key building
block in the creation of
polycarbonate

 plastics (#7) and epoxy resins
and coatings. Polycarbonate plastics are widely used in hemodialysis in
the formation of dialyzer casings and the epoxy resins are used to
secure the hollow fibres within the casing.

Under specific conditions, both BPA and DEHP will leach from the
respective products into the bloodstream. As endo-crine disruptors, BPA
and DEHP mimic normal human hormones and may lead to negative health
outcomes. The amount of DEHP and BPA that will leach out depends on the
temperature, the lipid content of the liquid, and the duration of
contact with the plastic (Mercola, 2011).

When considering contact time during hemodialysis, warm blood
(37[degrees]C) containing various lipid products comes into contact with
both blood tubing and dialyzers for approximately four hours every other
day. Due to the continual exposure to these chemicals, patients may
develop a high level of these chemicals in their blood. Health care
workers can also absorb these chemicals through the
dermal
 /der·mal/ () pertaining to the dermis or to the skin.



 or der·mic
adj.
Of or relating to the skin or dermis.
 manipulation
of these products and the inhalation of dust from medical devices
containing these chemicals. These endocrine disruptors have been linked
to obesity, cancer, neurological and repro-ductive impairment, thyroid
dysfunction, and even changes to a person's
DNA
 see nucleic acid.

DNA
 or deoxyribonucleic acid

One of two types of nucleic acid (the other is RNA); a complex organic compound found in all living cells and many viruses. It is the chemical substance of genes.
 (Solomon &
Schettler, 2012).

The risks we take today by using medical products that we know
could have serious health consequences down the road will have a direct
impact on the costs of providing health care services in the future.
Under our current model where lower-priced--yet toxic products--are
accepted, we most certainly will see not only an increase in service
cost, but, more importantly, a rise in the number of chronically ill
individuals, leading to increased demand for services to address the
untoward effects of medical toxins, and even longer wait times for
services needed from an already pressured system.

Unfortunately, as long as we maintain status quo by using the
products we use today, the future of our current health care delivery
model is in serious jeopardy. Such a system can only function for so
long. Albert Einstein said it well, "We can't solve problems
by using the same kind of thinking we used when we created them".
Health care providers and their patients should not serve as Petri
dishes for the various toxic time-bombs that await us in the medical
devices used today. Our patients will not get better; they will only
become more ill due to new complications. Only the medical device
manufacturers themselves gain if we turn a blind eye to the risks of
their products.

So what lies ahead and what solutions do we have?

Fortunately, large government agencies have finally begun to take
notice of the fact that potentially noxious chemicals are being found in
medical applications. Health Canada and the Food and Drug Administration
(FDA) are beginning to take a very close look at these serious concerns.
As of October 13, 2010, Health Canada declared that BPA was a health
toxin, something which had first been considered in 2008. Immediate
action must be taken to remove these toxic substances from common
hemodialysis apparatus such as dialyzers and blood tubing. Using green
chemistry and finding a substitute for DEHP and BPA must be considered
best practice moving forward. Some European companies, such as BBraun,
Gambro and Fresenius have already begun removing these substances from
their products. Unfortunately, most of their North American subsidiaries
have not yet adopted these same initiatives, but the pressure is on. In
October 2011, Baxter Healthcare became the first medical device
manufacturer to bring a toxin-free dialyzer to the North American market
under the Xenium+ label. Establishing a green procurement policy and
sourcing products that meet healthy criteria will
situate
  
tr.v. sit·u·at·ed, sit·u·at·ing, sit·u·ates
1. To place in a certain spot or position; locate.

2. To place under particular circumstances or in a given condition.

adj.
 safer products
at the point of use.

Finally, your voice may be our most valuable tool. All companies,
medical companies included, look to provide profits to their
shareholders, so they recognize that a negative image is bad business.
Let your representative know your position and that you will be sourcing
a less harmful option. Those of us who choose to speak up will hopefully
motivate them to make the right choice and, thus, establish a new model
in sustainable hemodialysis and health care.

About the author

Rejean Quesnelle is a graduate of the Georgian College Dialysis
Technology Program. Rejean has more than eight years of experience in
the dialysis field and is currently employed by Halton Healthcare
Services in Oakville, Ontario. Rejean can be reached via email at
regq101@gmail.com or phone 705-718-7474.

References

Calafat, A.M., Weuve, J., Ye, X., Jia, LT., Hu, H., et al. (2008).
Exposure to Bisphenol A and other phenols in
neonatal intensive care
unit

 premature infants. Environ Health Perspect, 117(4).
doi:10.1289/ehp.0800265

Environment Canada (2012).
CEPA

CEPA Canadian Energy Pipeline Association
CEPA Comisión Ejecutiva Portuaria Autónoma
 Environmental Registry (update
2012). Retrieved from http://www.ec.gc.ca/lcpe-cepa/

Environmental Working Group (2007-2012). Phthalates. Retrieved from

http://www.ewg.org/chemindex/term/480

Mercola, J. (2011). One of the top 6 chemical threats to humans.
Retrieved from http://search.mercola.com/search/Pages/results.aspx?k=one%20of%20thecro20top%206

Solomon, G., & Schettler, T. (2000). Environment and health: 6.
Endocrine disruption and potential human health implications.
Canadian
Medical Association Journal

, 163(11), 1471-1476.

Retrieved from http://www.cmaj.ca/content/163/11/1471.full

Statistics Canada (2011). Canadian Health Measures Survey: Lead,
bisphenol A and mercury. Retrieved from

http://www.statcan.gc.ca/daily-quotidien/100816/dq100816a-eng.htm

Tickner, J.A., Schettler, T., Guidotti, T., McCally, M., &
Rossi, M. (2001). Health risks posed by use of Di-2-ethyl-hexyl
phthalate (DEHP) in
PVC
 see polyvinyl chloride.


PVC
 in full polyvinyl chloride

Synthetic resin, an organic polymer made by treating vinyl chloride monomers with a peroxide.
 medical devices: a critical review. American
Journal of Indian Medicine, 39(1),100-11. Retrieved from

http://www.ncbi.nlm.nih.gov/pubmed/11148020

Wikipedia (n.d.) Bisphenol A. Retrieved from Wikipedia:

http://en.wikipedia.org/wiki/Bisphenol_A

Wilding, B.C., Curtis, K., & Welker-Hood, K. (n.d.). Hazardous
chemicals in healthcare: A snapshot of chemicals in doctors and nurses.
Retrieved from http://www.psr.org/assets/pdfs/hazardous-chemicals-in-health-care.pdf

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