Methemoglobinemia in critically ill patients during extended hemodialysis and simultaneous disinfection of the hospital water supply

Hemodialysis is the most commonly used treatment for patients with end-stage renal disease. In the United States, approximately 3,500 hemodialysis centers provide hemodialysis therapy to more than 250,000 patients.1 Municipal water must be treated to remove impurities that would be toxic to patients undergoing dialysis. Almost all hemodialysis water treatment systems include a reverse osmosis unit, which removes a variety of toxic substances, and many include deionization (ie, cationic, anionic, or mixed bed) tanks, which remove positively or negatively charged ions and replace them with hydrogen and hydroxyl ions.2 Because reverse osmosis membranes are subject to bacterial overgrowth and scale formation, they must be rou-tinely cleaned, disinfected, and rinsed.3,4 Cleaning may be

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