I Hate Dialysis Message Board

Dialysis Discussion => Dialysis: Home Dialysis - NxStage Users => Topic started by: slipkid on May 14, 2014, 04:54:28 PM

Title: Sak Recall
Post by: slipkid on May 14, 2014, 04:54:28 PM
Just got a phone call from my unit that Nxstage has issued a recall on Saks.

The affected lot number (so I was told) is for SAK-307, 40179125.  Instructionss are to drain and use bags is one of the bad Saks is in the machine.

Alleged reason is high aluminum levels.

I been using the affected SAKs for two weeks.  Our latest delivery is OK.

Curiously, the unit had not heard of the oversized PAks... YET!
Title: Re: Sak Recall
Post by: Hemodoc on May 14, 2014, 09:19:23 PM
Nice, my aluminum has been high for the last three months without explanation. Nice.
Title: More news on the SAK recall
Post by: slipkid on May 15, 2014, 07:57:23 AM
More news on the SAK recall.

The lot number I gave yesterday is NOT the only one affected with high aluminum.

My nurse at Davita is coming to my house in an hour to take a blood sample for testing, so these folks are sufficiently shaken up to run a test.

Symptoms of aluminum toxicity are agitation, mental confusion, and muscle rigidity - convulsions.  I convulsed last night during dialysis that scared  the daylights out of my wife.

I am definitely suffering from agitation, 'cause I'm as mad as hell.
Title: Re: Sak Recall
Post by: obsidianom on May 15, 2014, 09:16:21 AM
Here is the latest direct from the company. Any sak type could be involved.  The involved Lot numbers all start with 401 and 305. As far as they know , that is it. I am working on finding out more. I will post as I find out. The saks were produced last spring so they have been out there awhile.
Title: Re: Sak Recall
Post by: cdwbrooklyn on May 15, 2014, 12:56:12 PM
My nurse just called me at work 1/2 hour ago to tell me to text her my SAKs lot numbers when I get home.  I know for sure that I'm using 401 and have to drain my Pure Flow tonight.  I'm glad this is my off night.  No wonder I felt confused most of the time, a little agitated, and some muscle rigidity.  DaVita is slacking up.... Praise God that they discover this problem.   :o
Title: Re: Sak Recall
Post by: obsidianom on May 15, 2014, 01:19:44 PM
Its not all saks that begin with 401. So make sure you check the entire number .
Anyone who has been using the contaminated saks should talk to their nurse and or doctor to consider checking their aluminum levels.
Title: Re: Sak Recall
Post by: Simon Dog on May 15, 2014, 01:53:41 PM
I just got an email from the RN at my clinic telling me not to use SAKS 40179162 and 40179163 (she checked the records and alerted me to the recalled SAKs that I was shipped).  Of course, I get this email the day after I use my last SAK in the recalled batch.   She also advised I need to draw a navy blue topped tube for an AL test at the next monthly labs.
Title: Re: Sak Recall
Post by: obsidianom on May 15, 2014, 02:00:03 PM
I am concerned about the past 12 months since the saks were manufactured last May. WE are having NxStage go back over the past year and see if we used any of the contaminated saks. Then if we did we will draw the aluminum levels.  Isnt this fun.
Title: Re: Sak Recall
Post by: Simon Dog on May 15, 2014, 02:17:36 PM
WE are having NxStage go back over the past year and see if we used any of the contaminated saks.
This sort of thing is why I keep my treatment flow sheets in an SQL database  8) - It makes it real easy to look this sort of thing up.
Title: Re: Sak Recall
Post by: cdwbrooklyn on May 15, 2014, 02:27:09 PM
WE are having NxStage go back over the past year and see if we used any of the contaminated saks.
This sort of thing is why I keep my treatment flow sheets in an SQL database  8) - It makes it real easy to look this sort of thing up.

I should start doing that...this thing is crazy.  Like we don't have enough problems.  :banghead;
Title: Re: Sak Recall
Post by: Bill Peckham on May 15, 2014, 02:36:29 PM

These are the lot numbers of the SACs in question:


Jan 2014   40179127, 40179107,40179106,40179105, 40179093,40179034
Dec 2013  31279120, 31279118
May 2013  3057921,3057920,3057915,3057914,3057906,3057905
April 2013  3047924,3047923


Note I am not sure if these are the complete list or just the ones relevant to NKC
Title: High aluminum levels
Post by: slipkid on May 15, 2014, 04:11:36 PM
I have gone back through my blood test results, and aluminum levels are taken yearly by Davita.

My January 2014 level for aluminum was 18 (no units given on data sheet... really scientific!!!!)

The reference range is 0-9.

So I am 100 percent above the high limit, and INFINITY above the low limit.

This may explains some of the symptoms I have been having post dialysis that I have not related to this forum.

This shoots a cannonball through the notion of the so-called "ultra-pure" dialysate that has been trumpeted by some on this board.  I asked my nurse this morning whether the FDA has been notified and she said yes.  The recall is not on the FDA's website yet, but it does show a number of recalls on Pure Flow SAks for a number of years.

My nurse also took a water sample from the Pure Flow.

I want this shit out of my system.  What is Davita going to do about it (presumably Fresenius as well) and how fast are they going to move?

NEEDLESS to say, everyone should be tested for aluminum.
Title: Re: Sak Recall
Post by: Speedy1wrc on May 16, 2014, 04:11:27 AM
Your center should have an email from NxStage with the affected SAK numbers and the associated lot numbers. There are different lot numbers for different SAK numbers. I had clinic yesterday so my nurse gave menthe complete list, and it's long. Everyone should get a copy of the letter soon. You will need to verify whether you have any of the bad SAK's and that you have been informed of the problem.

This explains a lot. When I started home hemo on bags my aluminum level was normal. When I started using the Pureflow it skyrocketed. We eliminated all of the usual suspects and my nurse even called NxStage to verify it wasn't coming from the SAK's. She was assured by them that everything was normal with the SAK's.

My aluminum is very high and I have had the typical symptoms, so this concerns me. I am also curious if it actually could affect bags too. The problem is with batches of the lactate used to manufacture the product. I wonder if that same lactate was used to manufacture bags as well.

The nurse drew an aluminum on me yesterday.
Title: Re: Sak Recall
Post by: obsidianom on May 16, 2014, 05:06:18 AM
I am interested in everyones symptoms. Please list your sypmtoms you believe are related to aluminum.
Title: Re: Sak Recall
Post by: slipkid on May 16, 2014, 06:49:15 AM
@ Speedy1wrc

I have been concerned about the lactate in the dialysis for some time.

I had my blood levels checked before and after a session and the level was 10 mg/dL (reference range 4-16 mg/dL) at the start of the session and 56 mg/dL at the end of the session.  This is a 460 percent increase.  No one at Davita seemed concerned, but I was shocked.

I requested changing to bicarbonate dialysate, but Nxstage turned me down (so I was told by Davita).




Title: Re: Sak Recall
Post by: slipkid on May 16, 2014, 06:54:01 AM
I spoke to legal counsel yesterday, and he cautioned me to revealing symptoms of alleged aluminum poisoning on an open forum.

He also recommended I hold on to any unused SAKs affected by the recall, and not turn them back to the dialysis clinic.

I wonder why?
Title: Re: Sak Recall
Post by: obsidianom on May 16, 2014, 07:40:02 AM
No one seems to have posted symptoms. I am really interested in that as a doctor and spouse of patient.
Title: Re: Sak Recall
Post by: Hemodoc on May 16, 2014, 09:21:34 AM
@ Speedy1wrc

I have been concerned about the lactate in the dialysis for some time.

I had my blood levels checked before and after a session and the level was 10 mg/dL (reference range 4-16 mg/dL) at the start of the session and 56 mg/dL at the end of the session.  This is a 460 percent increase.  No one at Davita seemed concerned, but I was shocked.

I requested changing to bicarbonate dialysate, but Nxstage turned me down (so I was told by Davita).

Lactate is converted to bicarb in the liver. As long as you have a healthy liver, not a big deal.
Title: Re: Sak Recall
Post by: slipkid on May 16, 2014, 10:04:23 AM
@ Hemodoc

My research revealed that some lactate is converted in the brain, which makes lactate as a potential source of aluminum potentially more significant.

Nevertheless, we are entitled to a thorough investigation of the dialysate Nxstage is using, from the Pure Flow concentrate as well as to the bags.  Nothing less will satisfy me.
Title: Re: Sak Recall
Post by: Simon Dog on May 16, 2014, 10:07:17 AM
@ Speedy1wrc
I requested changing to bicarbonate dialysate, but Nxstage turned me down (so I was told by Davita).
NxStage did not turn you down.   The NxStage system is lactate based; the BabyK and 2008 series Fresenius machines are bicarb based.    NxStage could inform you "we don't have a bicarb based system", however, only your clinic or Dr. could actually "turn you down". 

Quote
I spoke to legal counsel yesterday, and he cautioned me to revealing symptoms of alleged aluminum poisoning on an open forum.

He also recommended I hold on to any unused SAKs affected by the recall, and not turn them back to the dialysis clinic.
He wants to preserve your ability to file contingency fee litigation, and wants the bags preserved as evidence.   "Don't talk about the case except to your legal team" is the first thing any civil or criminal lawyer will tell the client.
Title: Re: Sak Recall
Post by: Simon Dog on May 16, 2014, 10:10:20 AM
I was contacted by the RN who supports my dialyis and told lot numbers 40179162 and 40179163 were included in the recall (she only informed me of lot numbers I was on record as having received).

These are the lot numbers of the SACs in question:


Jan 2014   40179127, 40179107,40179106,40179105, 40179093,40179034
Dec 2013  31279120, 31279118
May 2013  3057921,3057920,3057915,3057914,3057906,3057905
April 2013  3047924,3047923


Note I am not sure if these are the complete list or just the ones relevant to NKC
Title: Re: Sak Recall
Post by: slipkid on May 16, 2014, 10:21:13 AM
@ Simon Dog

Nxstage has a bicard-based Pure Flow concentrate, I have a copy of the FDA letter approving it use.  You'll also find with some research the SAK types and element concentrates.

Re lawyers:  My comment was rhetorical.  If patients have high aluminum levels from the dialysate there may be legal liability if damage has been caused.  Believe what you want, but I had good reasons for consulting with counsel considering the potential toxicity of aluminum poisoning.

My neph told me Nxstage turned me down for the bicarb-based Pure Flow product.
Title: Re: Sak Recall
Post by: Bill Peckham on May 16, 2014, 10:30:51 AM
I think this is the complete list of the SAC lot numbers in question
>PDF Attached< must be logged in to view
Title: Re: Sak Recall
Post by: Bill Peckham on May 16, 2014, 10:33:12 AM
I believe the bicarb based dialysate is for their acute operations; it is not available for their chronic operations due to the shortened (nearly nil) shelf life of bicarb based dialysate.
Title: Re: Sak Recall
Post by: slipkid on May 16, 2014, 01:56:04 PM
Bill:

The bicarb-based PAKs are a two stage design which requires mixing before use.  Shelf life is not the issue.  Nxstage profits are.
Title: Re: Sak Recall
Post by: Hemodoc on May 16, 2014, 02:25:05 PM
Yup, and they are only used in the ICU setting for continuous dialysis regimens in the critically ill. They do not use them with the home patient population. I know, I asked due to their lower sodiium levels quite recently.
Title: Re: Sak Recall
Post by: Bill Peckham on May 16, 2014, 03:07:57 PM
Bill:

The bicarb-based PAKs are a two stage design which requires mixing before use.  Shelf life is not the issue.  Nxstage profits are.


The current lactate SACs have a 96 hour shelf life, the bicarb system needs to be used as soon as it is made.
Title: Re: Sak Recall
Post by: Zach on May 16, 2014, 04:14:30 PM
From a letter to NxStage patients:

UPDATED* Voluntary Medical Device Recall SAK Dialysate Concentrate
SAK-301, SAK-302, SAK-303, SAK-304, SAK-305, SAK-306, SAK-307, SAK-407

May 15, 2014

Dear NxStage Customer:

Description of Problem

NxStage Medical, Inc. has confirmed through internal testing that specific lots of SAK Dialysate Concentrate contain aluminum levels which exceed internal product specification. NxStage Medical, Inc. was made aware of the issue through customer complaints indicating an increase in the serum aluminum levels of patients over a one year period identified during routine, annual blood tests. There have been no adverse health consequences or medical interventions reported.

The NxStage SAK concentrate, a component of the NxStage Pureflow SL module, is intended to contain the essential electrolytes, buffer, and glucose in the appropriate concentrations that when proportioned with purified water produces dialysate. The NxStage Pureflow SL module is an optional accessory to the NxStage System OneTM that prepares dialysate for use during hemodialysis, as prescribed by the physician.

The affected products and lots can be found in Attachment A.

The affected lots were manufactured between April 2013 and February 2014.

Potential Risk

NxStage Medical, Inc. initiated an extensive investigation and confirmed that specific lots of sodium lactate, a raw material used in the production of the SAK dialysate concentrate, contained levels of aluminum which would exceed specification when the concentrate was fully diluted.

There have been no adverse health consequences or medical interventions reported. Specifically increases in patient serum aluminum levels averaging 10μg/L have been reported within specific dialysis networks. The aluminum levels of the affected lots range from 11.5 μg/L to 13 μg/L when the concentrate is fully diluted. The product specification requires concentrate aluminum levels to be less than 10 μg/L. NxStage believes that the likelihood of any serious adverse health consequences is remote at the serum aluminum levels currently reported. NxStage has confirmed that other SAK lots in distribution meet the specification for aluminum levels.

The complete letter:
http://ww2.nxstage.com/rs/nxstagemedicalinc/images/NxStage%20Recall%20Notice%205%2015%202014%20Updated.pdf?mkt_tok=3RkMMJWWfF9wsRokuq%2FJZKXonjHpfsX56ugqXaS2lMI%2F0ER3fOvrPUfGjI4DTMFkI%2BSLDwEYGJlv6SgFSrjEMbhiybgFWRE%3D
Title: Re: Sak Recall
Post by: Hemodoc on May 16, 2014, 06:22:11 PM
I am quite disappointed in the NxStage letter implying that the levels of aluminum in patients will only be about 10 with the normal level up to 9. Not true, mine two months ago was over 20. Sorry, but not happy with this whole episode. Where is their quality control that patients have to tell NxStage that there is a problem Houston. That is NOT the way it is supposed to work.
Title: Re: Sak Recall
Post by: obsidianom on May 17, 2014, 06:37:28 AM
Read this article fully about aluminum and its effects in dialysis patients.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3524902/
Title: Re: Sak Recall
Post by: obsidianom on May 17, 2014, 06:45:32 AM
This shows that bicarbonate dialysis can also cause aluminum issues.


Kidney Int. 1995 Aug;48(2):469-74.

Epidemic aluminum intoxication in hemodialysis patients traced to use of an aluminum pump.

Burwen DR1, Olsen SM, Bland LA, Arduino MJ, Reid MH, Jarvis WR.

Author information

Abstract


This study was designed to identify the source, risk factors, and clinical consequences of an outbreak of aluminum intoxication in hemodialysis patients using case-control and cohort studies. In 1991, a dialysis center in Pennsylvania [Dialysis Center A (DCA)] identified a number of patients with elevated serum aluminum levels. All patients receiving dialysis at DCA during January 1, 1987 to March 26, 1992 were involved in the study. A case-patient was defined as any patient with a serum aluminum level > or = 100 micrograms/liter after > or = 5 dialysis sessions at DCA. Fifty-nine case-patients were identified. Risk factors for elevated serum aluminum levels were receipt of bicarbonate- (rather than acetate-) based dialysate, higher number of sessions using bicarbonate dialysis, receipt of acid concentrate (used in bicarbonate dialysis) passed through one of two electric pumps, and a greater number of sessions using this concentrate. The electric pumps had an aluminum casing, casing cover, and impeller. Elevated levels of aluminum were found in acid concentrate after passing through a pump. Seizures and mental status changes requiring hospitalization were associated with aluminum exposure. We found that epidemic aluminum intoxication was caused by the use of an electric pump with aluminum housing to deliver acid concentrate used in bicarbonate dialysis. This outbreak demonstrates why it is essential to insure that all fluid pathways, storage tanks, central delivery systems, and pumps are compatible with low pH fluids before converting from acetate to bicarbonate dialysis.
Title: Re: Sak Recall
Post by: obsidianom on May 17, 2014, 08:00:42 AM
I am quite disappointed in the NxStage letter implying that the levels of aluminum in patients will only be about 10 with the normal level up to 9. Not true, mine two months ago was over 20. Sorry, but not happy with this whole episode. Where is their quality control that patients have to tell NxStage that there is a problem Houston. That is NOT the way it is supposed to work.
11.1 To prevent aluminum toxicity, the regular administration of aluminum should be avoided and the dialysate concentration of aluminum should be maintained at <10 µg/L. (EVIDENCE)

11.1a CKD patients ingesting aluminum should not receive citrate salts simultaneously. (EVIDENCE)

11.2 To assess aluminum exposure and the risk of aluminum toxicity, serum aluminum levels should be measured at least yearly and every 3 months in those receiving aluminum-containing medications. (OPINION)

11.2a Baseline levels of serum aluminum should be <20 µg/L. (OPINION)

Title: Re: Sak Recall
Post by: obsidianom on May 17, 2014, 09:55:16 AM
Remember this from last fall? She had high aluminum and didnt know why. Now we know.

Angiepkd
Full Member

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Posts: 441


    High aluminum
« on: November 08, 2013, 09:30:52 PM »   

--------------------------------------------------------------------------------
Hi all!  For the last 3 or 4 months my aluminum level has been climbing.  This month it is up to 30.  I have stopped using antiperspirant, checked my lotions and make up and quit cooking with aluminum pans.  Nothing seems to help.  When I spoke with my nurse today she told me they have several patients whose aluminum levels are elevated, and the doc can't figure it out.  Anyone else have this issue with NxStage?  I use a SAK 303.  Not sure what to do to get those levels down.  Thanks for any help!   
 
Title: Re: Sak Recall
Post by: Hemodoc on May 17, 2014, 01:20:05 PM
My nephrologist put me on Zinc supplements to help against the high aluminum levels a couple of months ago. If NxStage is reporting that the average level was "10" then we already have two outliers here on this thread alone. I don't believe we have seen the full depth of this horrible event. Where was their quality control since this STARTED last April. I didn't start on Pureflow until July. With a successful quality assurance program, theoretically, I should have never been exposed to this 3 months after the problem began. Instead, I have endured 10 months of exposure to aluminum and the horrible side effects of aluminum well described in the literature. NxStage needs to NOT white wash this issue. That letter I believe is misleading and could give patients false reassurance when in fact, they may be at risk. This is one person NOT happy at all with NxStage at the current time and I am not the least bit tempered in that opinion by this letter.
Title: Re: Sak Recall
Post by: slipkid on May 17, 2014, 02:55:53 PM
Hemodoc, you express my sentiments quite well.  Among the many questions I have are (1) "likelihood of any serious adverse health consequences is remote," claims Nxstage.  What adverse effects (even seeming minor ones as Nxstage might define it) have been reported?  What physical and mental symptoms have been reported that should be monitored and addressed?

Question (2) is why is there any aluminum in the SAKS AT ALL?  Sodium lactate in its chemical form contains no aluminum ions.  How the hell did the aluminum get into the lactate to begin with?

As I have written before, an FDA investigation is called for to get to the truth that Nxstage has yet to reveal.


 
Title: Re: Sak Recall
Post by: Hemodoc on May 17, 2014, 03:10:30 PM
Hemodoc, you express my sentiments quite well.  Among the many questions I have are (1) "likelihood of any serious adverse health consequences is remote," claims Nxstage.  What adverse effects (even seeming minor ones as Nxstage might define it) have been reported?  What physical and mental symptoms have been reported that should be monitored and addressed?

Question (2) is why is there any aluminum in the SAKS AT ALL?  Sodium lactate in its chemical form contains no aluminum ions.  How the hell did the aluminum get into the lactate to begin with?

As I have written before, an FDA investigation is called for to get to the truth that Nxstage has yet to reveal.

Absolutely. The PAK issues recently, this and the fact that they have too high a sodium level that the head of "solutions" for NxStage a couple of weeks ago didn't seem the least bit interested in addressing leads me to wonder how much longer NxStage will be in my future. I am expecting a more robust company response. If not, then they will not be my choice any longer at a minimum.
Title: Re: Sak Recall
Post by: slipkid on May 17, 2014, 06:28:29 PM
Hemodoc:

Again, you have expressed my feelings about Nxstage and continuing the use of the Nxstage therapy system.
Title: Re: Sak Recall
Post by: slipkid on May 17, 2014, 06:39:41 PM
I have reviewed the Nxstage product recall letter which is addressed to CUSTOMERS of Nxstage.  I am a patient associated with a Davita clinic.  Davita is Nxstage's customer.

I see no reason why I am obligated to fill out and SIGN the "Recall Reply Form" they have attached to their recall notification.

I will discuss the ramifications of this form with my attorney on Monday, however, I foresee that he will reach the same conclusion as I have  noted above.
Title: Re: Sak Recall
Post by: Hemodoc on May 17, 2014, 07:21:20 PM
I have reviewed the Nxstage product recall letter which is addressed to CUSTOMERS of Nxstage.  I am a patient associated with a Davita clinic.  Davita is Nxstage's customer.

I see no reason why I am obligated to fill out and SIGN the "Recall Reply Form" they have attached to their recall notification.

I will discuss the ramifications of this form with my attorney on Monday, however, I foresee that he will reach the same conclusion as I have  noted above.

Yup, same here.
Title: Re: Sak Recall
Post by: Zach on May 17, 2014, 07:36:42 PM
I am really saddened and outraged by what my friends here at IHD are going through with regard to this NxStage fiasco.
This problem with aluminum in some of the dialysate concentrate SAKs has been going on since April 2013. How has it taken this long for the folks at NxStage to figure this out?  Is there no continuous quality control?

 :cuddle;
Title: Re: Sak Recall
Post by: Angiepkd on May 17, 2014, 08:00:59 PM
Wow! Thanks for the message to check out this thread, Obsidianom!  I hadn't paid attention to this particular thread because it was about a recall, and I received a transplant 10 weeks ago.  It makes me so angry that no one at DaVita mentioned this to me.  Everyone kept accusing me of using something containing aluminum that I wasn't telling them about.  I had my water tested multiple times, quit using antiperspirant, checked my cosmetics and lotions and never could figure it out. My neph even took me off of the sodium bicarbonate because of an association between baking soda and high aluminum.  My levels did come down, but were still above the recommended numbers.  I am wondering if I should have my aluminum levels tested now that I have a new kidney.  I was still around 17 prior to surgery, and aluminum isn't checked at my transplant clinic.  Any opinions on this?  I am also going to call my dialysis nurse on Monday to make sure the other patients with high aluminum were notified of the recall.  I can't remember any specific symptoms (which may be a symptom?!) but since I was pretty new to D, I wasn't sure if the things I experienced were normal for people on D.  I will speak to my transplant neph about this when I see him in June.  Thanks again, Obsidianom!
Title: Re: Sak Recall
Post by: slipkid on May 18, 2014, 12:38:01 PM
@ Zak:

Let me add to your understanding of the aluminum contamination in the Nxstage dialysate.

The Nstage recall letter - which Hemodoc has pointed out is quite misleading -  claims that, "The product specification requires concentrate aluminum levels to be less than 10 micrograms per liter."

The operative language is "concentrate aluminum levels to be less than 10 micrograms per liter."  The issue is why is there ANY aluminum in the concentrate (the SAKs) at all?  Nxstage claims the Pure Flow system delivers ultra-pure dialysate which is mere company propaganda.  "Pure Flow", in fact, does NOT deliver contaminate-free dialysate.  The published list of elements and compounds in the SAKs by Nxstage make no mention of aluminum contamination.  It is also likely that the dialysate bags also contain aluminum contamination.  What other contaminates, metal or otherwise are contained in the Pure Flow concentrate SAKs or the bags?

I have been using the Pure Flow system for 18 months, and I have experienced side effects which were reported to my neph many months ago.  Others have been using the Pure Flow system or bags for many years.  What consequence to exposure to aluminum has been caused?  What symptoms of exposure to aluminum toxicity have we been living with that have been dismissed  by the professionals involved with our system of treatment?  My own blood tests of excessive aluminum in the blood was either overlooked or ignored by my neph.

The issue of aluminum contamination is somewhat analogous to the mesothelioma debacle (asbestos exposure).  Patients exposed to asbestos were not diagnosed with the disease until decades had passed after exposure.   Post mortem autopsies of Alzheimer patients have revealed aluminum in the brain.  It is theorized that exposure to aluminum contamination has caused the latent or early onset of Alzheimer's.  Are patients using the Nxstage therapy faced with a similar fate, notwithstanding any present side effects we may be experiencing?

I trust this gives you a better understanding of why some of us are furious with Nxstage (and others for that matter).



 
Title: Re: Sak Recall
Post by: Dannyboy on May 18, 2014, 01:43:09 PM
How is 'Serum Aluminum' listed on my lab results listing?
I don't recognize anything with 'Aluminum' in it?

I' ve been using a  bunch of the recalled SAKs.
Title: Re: Sak Recall
Post by: obsidianom on May 18, 2014, 01:54:41 PM
How is 'Serum Aluminum' listed on my lab results listing?
I don't recognize anything with 'Aluminum' in it?

I' ve been using a  bunch of the recalled SAKs.
In most clinics it is only done once a year or every few months. It has to be specially drawn and ordered. Ask your nurse to draw it. It should just say aluminum.
Title: Re: Sak Recall
Post by: Dannyboy on May 18, 2014, 02:18:08 PM
Hmmm.   I will request a specific Aluminum test tomorrow (Monday) from my Davita nurse.
Thank you obisdianom.

Like others here, I'm pissed/dismayed over this situation.  Plus, Davita hasn't contacted me about this (got the news here and in an email from NxStage).   The NxStage letter sure downplays this issue.

Will be interesting to see when their SEC filings comment on this (none so far as I could find).  The degree to which *NxStage* will acknowledge potential negative financial impact will be interesting too, as a possible indicator of how "big a deal" this will turn out to be.

(Interestingly a Senior Vice President of NxStage just unloaded around $60K of common stock on Thursday (he still owns much more)).

---Dan
Title: Re: Sak Recall
Post by: Zach on May 18, 2014, 02:48:09 PM
For those who may be interested:

NxStage Medical, Inc. 2014 Annual Shareholder Meeting
Thursday, May 22, 2014 - 10:00AM EDT
Held at the Lanam Club:
260 North Main Street, Andover, MA

DIRECTIONS to the Lanam Club:
Continue on Route 93 North through Boston to Route 495 North (Exit 44A) (approximately 15 miles). Once on Route 495 North, take the Route 28 South / Andover exit (# 41). At this point, the Lanam Club is 1 mile ahead on the right. Parking is on the side of the building. Please use the Main Entrance in the front.

You can contact NxStage Medical, Inc.'s Board of Directors to provide comments,
to report concerns, or to ask a question, at the following address:

Corporate Secretary
NxStage Medical, Inc.
350 Merrimack Street
Lawrence, MA 01843

SEC Filings
http://ir.nxstage.com/sec.cfm

 8)
Title: Re: Sak Recall
Post by: Bill Peckham on May 19, 2014, 12:26:43 AM
How much aluminum is in incenter dialysate? In city water? We take for granted that the saline is saline and the heparin is heparin but no one actually knows. In the heparin case it turned out that the Chinese pig intestines used to make heparin was tainted early in the procurement process. In this case, one of the inputs was adulterated. Pointing at stock sales and alleging company malfeasance is a stretch.

The alternative is not peeing, the alternative is, for most, incenter, conventional hemo. In a unit an aluminum wrench fell into the dialysate tank and everyone was dosed with aluminum that way. We are all relying on averages, on average the water is x or the dialysate is y. No one is checking the dialysate that is used at the station, when it has been checked as part of due diligence for one study or another it has been constantly found to vary widely from the prescription.

No matter which machine you use at home or incenter, you are relying on manufactured inputs. The lesson here is to be more suspect of the process. What should bother the dialysis units is their reaction when their patients had an elevated aluminum. Instead of harping about aluminum foil ?! better to first check the dialysate.

We’ll know units are applying this lesson if people who are having trouble with thirst (aka sodium) first have their dialysate checked before being given the sodium lecture. Again.
Title: Re: Sak Recall
Post by: Zach on May 19, 2014, 06:25:12 AM

We’ll know units are applying this lesson if people who are having trouble with thirst (aka sodium) first have their dialysate checked before being given the sodium lecture. Again.


So true, Bill.

The dialysate level a dialysis machine reads, say 14.0, and the actual level may vary greatly.
 
That's why when I was doing self-care at my center, we always checked our machine before each treatment with a conductivity meter.

When centers don't independently verify the dialysate level, patients could be unnecessarily cramping during treatment (due to a low dialysate level) or become terribly thirsty after treatment (too high a dialysate level)--and be blamed in either case for those results.

 8)
Title: Re: Sak Recall
Post by: Speedy1wrc on May 19, 2014, 09:15:52 AM
One hundred percent false that no adverse symptoms were reported to NxStage. Mine were. My nurse noticed a drastic increase in my Al levels from when I began home hemo till an aluminum test last Spring. We went through the whole list of possible sources including testing my tap water multiple times. There were no indications of any other external sources other than the dialysate. In addition she noticed the exact same response in another patient also using the Pureflow. Her other patients using  bags did not have the same elevated Al levels. In all cases the labs were drawn at the same times and sent to the same lab for analysis.

She contacted NxStage with her concerns about the dialysate and was told it was not possible that it could be contaminated. NxStage knew there was a potential for contamination as early as June of last year and did nothing about it.

I have been experiencing severe memory loss and an overall malaise since last Spring when I started with the Pureflow. I am incensed that NxStage "apologizes for any inconvenience"  due to this incident. I also think that the list of affected SAK's is woefully misleading. I truly believe the number is much higher. If I were to guess, those lot's were identified only because they had examples to test. I suspect there were many other lot's which were also contaminated but there is no data.

I am also contacting a lawyer.
Title: Re: Sak Recall
Post by: caregivertech1 on May 19, 2014, 12:58:43 PM
Here's our "inconvenience".  Al level went to almost 30 last July. Bought all new stainless steel cookware, stopped using everything that contained aluminum, went to bottled water for drinking and cooking, went back in center twice for a month each time which reduced level to 10.....only to go back to 25 when  we returned home to contaminated sacs. Only Nxstage users experienced this since last Summer. Duh???? Couldn't get my nurses at Fresenius to even think about the saks. Unbelievable!!
Title: Re: Sak Recall
Post by: Speedy1wrc on May 19, 2014, 06:16:09 PM
I've been searching for any information about this recall and did find some interesting information. I ended up at the FDA site and there are an amazing number of entries for NxStage. They are both recalls incident reports. There are currently 1530 incidents listed in their database.

Some curious things I gathered. As I suspected some "product" is manufactured not in the US but in Mexico. So no surprise at the lack of quality control. But a common theme is saw in a handful of incident reports was blame being laid on the patient/user/operator. Many of the case were labeled as no cause found, must be operator error. I am seeing a theme with the way the PAK issues were (not) handled and how the mindset is at NxStage.

I also browsed the latest SEC filing and there was a lot of laying the foundation for failure. If this then scenario's.

I do not have a good feeling about any of this.
Title: Re: Sak Recall
Post by: slipkid on May 19, 2014, 06:29:00 PM
@ Speedy:

I would appreciate a link to the FDA page where you found the Nxstage incident reports.

I have been contacted by a member of the forum about a class action lawsuit and a party that is willing to listen.

Have you?
Title: Re: Sak Recall
Post by: Speedy1wrc on May 19, 2014, 07:14:28 PM
Just go to fda.gov. There is a search box where you type in NxStage. On the list of results it will first show recalls. Below that will be adverse events. Make sure to click on more results like this.

I too was contacted about a class action suit. I don't know who it was that sent me the email. The site it sent me too seemed somewhat legit but not enough to give me warm and fuzzy feelings about it. My lawyer is a personal friend so I will wait to see what he thinks of this whole thing.

Who will be the first to contact CNN?
Title: Re: Sak Recall
Post by: slipkid on May 19, 2014, 11:03:11 PM
Found the FDA adverse event database.  Thanks.
Title: Re: Sak Recall
Post by: obsidianom on May 20, 2014, 02:37:55 AM
From what i could read these FDA filings are nothing but mislabelings and user screw ups, and are OLD. Many are from 2005 to 2008 when the system was fairly new. I dont see any smoking guns.
Title: Re: Sak Recall
Post by: Maggie and Jeff on May 20, 2014, 07:57:05 AM
We have had issues with high aluminum for at least 18 months.
Title: Re: Sak Recall
Post by: Speedy1wrc on May 20, 2014, 08:49:16 AM
te author=obsidianom link=topic=31141.msg481995#msg481995 date=1400578675]
From what i could read these FDA filings are nothing but mislabelings and user screw ups, and are OLD. Many are from 2005 to 2008 when the system was fairly new. I dont see any smoking guns.
[/quote]That's more or less what I saw. However with so many "operator error" diagnosis it leads me to question so many "not our fault" findings. Is that truly a case of so many bad operators or a profound denial that anything is wrong? A lot of little errors is still indicative of a culture of mistakes. Where is the quality control? And arguably if that number of errors are caught, how many are missed? I have had issue with aluminum for some time as well. The denial that there could be any problem with the SAK's came directly from NxStage a year ago. Without anything to back it up, they flat out denied there could be anything wrong with the SAK's. A year ago they could have taken action so see if there was a problem. We went to them with our test results in hand to say we've eliminated everything else, we think there is a problem, but with the culture of denial they just dismissed it. Am I off base thinking that every lot should be tested? I test every batch for chloramines. Monthly I test the SAK for contamination. At least quarterly I check a PAK sample. I take every precaution to ensure my safety and well being, it doesn't seem like they do.
Title: Re: Sak Recall
Post by: Maggie and Jeff on May 20, 2014, 08:59:50 AM
From what i could read these FDA filings are nothing but mislabelings and user screw ups, and are OLD. Many are from 2005 to 2008 when the system was fairly new. I dont see any smoking guns.
That's more or less what I saw. However with so many "operator error" diagnosis it leads me to question so many "not our fault" findings. Is that truly a case of so many bad operators or a profound denial that anything is wrong? A lot of little errors is still indicative of a culture of mistakes. Where is the quality control? And arguably if that number of errors are caught, how many are missed? I have had issue with aluminum for some time as well. The denial that there could be any problem with the SAK's came directly from NxStage a year ago. Without anything to back it up, they flat out denied there could be anything wrong with the SAK's. A year ago they could have taken action so see if there was a problem. We went to them with our test results in hand to say we've eliminated everything else, we think there is a problem, but with the culture of denial they just dismissed it. Am I off base thinking that every lot should be tested? I test every batch for chloramines. Monthly I test the SAK for contamination. At least quarterly I check a PAK sample. I take every precaution to ensure my safety and well being, it doesn't seem like they do.

I agree.

In addition to the aluminum we have had high magnesium and can't find the source.
Title: Re: Sak Recall
Post by: obsidianom on May 20, 2014, 09:27:55 AM
High aluminum will cause hyper calcemia AND HYPERMAGNESIUM. So the magnesium is probably from the aluminum. My wife has high magnesium and high calcium.
Title: Re: Sak Recall
Post by: Speedy1wrc on May 20, 2014, 11:11:36 AM
In center my phosphorus was normal on 2 binders per day. My magnesium was low and aluminum was normal. Starting on NxStage my phosphorus jumped as did aluminum and magnesium.
Title: Re: Sak Recall
Post by: amanda100wilson on May 20, 2014, 01:00:44 PM
My first thought when I first became aeare of this recall.  Anecdotal evidence was brought to NxStage's attention for over a year.  Where was their random sampling for quality control before and during this time?  Why was this not identified by them?  Once they were being made aware of this problem, why wasn't the source identified sooner?
Title: Re: Sak Recall
Post by: Hemodoc on May 20, 2014, 02:04:14 PM
Actually, it was FMC that conducted a study of home PD, Home NxStage, Other home hemo and in-center patients showing that NxStage patients since mid 2013 had markedly elevated levels.  Not yet broadcast, but that is what happened.
Title: Re: Sak Recall
Post by: Angiepkd on May 20, 2014, 02:59:17 PM
From the research I did about high aluminum levels, the aluminum can be stored in organs like the heart and brain. Is there any way to know if we have excess aluminum in our organs?  And can anything be done to remove it?  I am definitely not liking the studies linking high aluminum levels to Alzheimer's.  Most of the websites claiming to remove aluminum from the body seem like scams to me.  I also read something about a chelation process, but was unclear if that would remove the stored aluminum. Any help would be appreciated!  Thanks.
Title: Re: Sak Recall
Post by: cariad on May 20, 2014, 03:16:54 PM
From the research I did about high aluminum levels, the aluminum can be stored in organs like the heart and brain. Is there any way to know if we have excess aluminum in our organs?  And can anything be done to remove it?  I am definitely not liking the studies linking high aluminum levels to Alzheimer's.  Most of the websites claiming to remove aluminum from the body seem like scams to me.  I also read something about a chelation process, but was unclear if that would remove the stored aluminum. Any help would be appreciated!  Thanks.
I've only heard about chelation with regards "treating" autism. From what I've read about it (years ago) it may remove heavy metals from your system, but it's dangerous. I think it goes in the scam column.
Title: Re: Sak Recall
Post by: Hemodoc on May 20, 2014, 03:23:38 PM
From the research I did about high aluminum levels, the aluminum can be stored in organs like the heart and brain. Is there any way to know if we have excess aluminum in our organs?  And can anything be done to remove it?  I am definitely not liking the studies linking high aluminum levels to Alzheimer's.  Most of the websites claiming to remove aluminum from the body seem like scams to me.  I also read something about a chelation process, but was unclear if that would remove the stored aluminum. Any help would be appreciated!  Thanks.
I've only heard about chelation with regards "treating" autism. From what I've read about it (years ago) it may remove heavy metals from your system, but it's dangerous. I think it goes in the scam column.

Not quite Cariad. Chelation is standard therapy for elevated levels of aluminum in dialysis patients, but higher than what is being reported at present.

http://emedicine.medscape.com/article/165315-treatment
Title: Re: Sak Recall
Post by: Angiepkd on May 20, 2014, 07:19:30 PM
Thanks for the info! My highest level was 30, and then came down to 16/17 and stayed there until my transplant in March, so it doesn't appear that chelation is something I need. Curious if there is a way to measure stored aluminum in the body?  The fact that I am worrying about this makes me very angry at NxStage!
Title: Re: Sak Recall
Post by: Speedy1wrc on May 20, 2014, 08:39:54 PM
It's controversial may best, but there is suggestion of using hair samples.
Title: Re: Sak Recall
Post by: Hemodoc on May 20, 2014, 10:09:16 PM
Thanks for the info! My highest level was 30, and then came down to 16/17 and stayed there until my transplant in March, so it doesn't appear that chelation is something I need. Curious if there is a way to measure stored aluminum in the body?  The fact that I am worrying about this makes me very angry at NxStage!

Measuring actual damage is not going to be an easy task. Adynamic bone disease is one side effect, but how many folks want a bone biopsy AND it is a risk for dialysis patients to begin with. Memory loss is subjective. Blood levels are certainly the easiest to obtain.  I have yet to hear of anyone with a level higher than 30 which means few would have need chelation with dexferoxamine.

I know subjectively, that since starting on the PureFlow last July, I have NOT felt as well as usual. Can that be related specifically to high aluminum levels? Not an easy task to measure objectively.

The unknown is what is the long term sequelae from this type of exposure over several months? I would venture that little is known on such an exposure at this point. The studies on aluminum exposure in dialysis patients are over two decades old when related to aluminum containing phosphorus binders.

Nevertheless, this entire episode is simply unacceptable. We will see how NxStage responds, but to date, I am not happy with this turn of events.
Title: Re: Sak Recall
Post by: Speedy1wrc on May 21, 2014, 06:22:53 AM
I have been trying to research such effects of long term elevated aluminum levels and indeed there isn't very much out there. While it appears clear that there is a distinct correlation, how much and for how long is still up for debate. While there is little argument we all have been harmed, a court would expect some sort of quantitative amount of damage which I don't know if anyone of us could prove. 
Title: Re: Sak Recall
Post by: Bill Peckham on May 21, 2014, 10:14:29 AM
I have been trying to research such effects of long term elevated aluminum levels and indeed there isn't very much out there. While it appears clear that there is a distinct correlation, how much and for how long is still up for debate. While there is little argument we all have been harmed, a court would expect some sort of quantitative amount of damage which I don't know if anyone of us could prove.


In addition I think there is an assumption that people who use dialysis aren't going to live long enough to have impacts 20 years hence.
Title: Re: Sak Recall
Post by: Hemodoc on May 21, 2014, 12:45:31 PM
The entire issue boils down to what quality assurance protocols does NxStage have in place. Obviously, there was a failure in manufacturing but that was NOT picked up by quality assurance in a timely manner. In fact, it appears to have been an external agent, FMS, that found the high aluminum was from NxStage patients alone. That in itself is a failure that NxStage will need to correct if they wish to regain confidence in their product.

With the entire issue of oversized PAK's which I just had another one two days ago that didn't fit and now this SAK issue, that is two fundamental product lines that are not subject to proper post marketing quality assurance BEFORE going to the consumer. How long before a manufacturing issue results in deaths instead of ill defined aluminum accumulations with poorly defined objective measurements of end organ damage or PAKs that don't fit. The harm of the aluminum is a difficult issue to define due to lack of studies, lack of objective end organ assessment and most likely lack of proper follow up by any agent keeping data in a universal data base of all affected. That is likely not going to occur since NxStage is the only one with that data base and it is not likely that they will follow each individual case. They have already referred us back to our individual units. What follow up studies will they do to see if there are any adverse effects from this episode? FMC, DaVita and DCI are the only agents that have the ability outside of NxStage. Will CMS follow this or the FDA? Shucks, I expect it will simply be white washed and cast away.

I have been considering changing over to the Baby K for a few months because of the volume issue with NxStage, not enough, but I have held on due to my appreciation of their ultra-pure dialysate. I am beginning to seriously question whether I SHOULD continue with NxStage waiting for the next shoe to drop so to speak. This entire episode leaves me with little confidence in them to pre-emptively self monitor for complications. Is NxStage a disaster waiting to happen?

We will see how they respond, but at present, my level of confidence in this company is at a very low level. We will see how they proceed.
Title: Re: Sak Recall
Post by: caregivertech1 on May 21, 2014, 03:28:08 PM
Hemodoc was right about FMC elevating this to NxStage after exhausted testing since last Summer. Kudos to a few medical directors and patients who made this happen.. Of course it took too long and along with others I'm not happy with NxStage's response . Got a feeling that will change. I hope so because I love their system.
Title: Re: Sak Recall
Post by: Hemodoc on May 21, 2014, 03:57:17 PM
Hemodoc was right about FMC elevating this to NxStage after exhausted testing since last Summer. Kudos to a few medical directors and patients who made this happen.. Of course it took too long and along with others I'm not happy with NxStage's response . Got a feeling that will change. I hope so because I love their system.

Most clinics have only a handful of patients on NxStage making it difficult to consider NxStage SAKs as the source. There are only two of us in my clinic with NxStage, but none of us put together that connection with NxStage. In retrospect, we should have but I had other confounding issues at the time with some of my medications that may have been simply a red herring leading us away from the correct diagnosis.
Title: Re: Sak Recall
Post by: caregivertech1 on May 21, 2014, 04:46:02 PM
Hemodoc was right about FMC elevating this to NxStage after exhausted testing since last Summer. Kudos to a few medical directors and patients who made this happen.. Of course it took too long and along with others I'm not happy with NxStage's response . Got a feeling that will change. I hope so because I love their system.

Most clinics have only a handful of patients on NxStage making it difficult to consider NxStage SAKs as the source. There are only two of us in my clinic with NxStage, but none of us put together that connection with NxStage. In retrospect, we should have but I had other confounding issues at the time with some of my medications that may have been simply a red herring leading us away from the correct diagnosis.

Hey, I know what you're saying. I too should have yelled louder or done more but at the end someone did listen....too late but you know what, it's over and just maybe NxStage will learn from this and we can again trust them.
Title: Re: Sak Recall
Post by: Bill Peckham on May 21, 2014, 11:08:37 PM

I have been considering changing over to the Baby K for a few months because of the volume issue with NxStage, not enough, but I have held on due to my appreciation of their ultra-pure dialysate. I am beginning to seriously question whether I SHOULD continue with NxStage waiting for the next shoe to drop so to speak. This entire episode leaves me with little confidence in them to pre-emptively self monitor for complications. Is NxStage a disaster waiting to happen?



This aluminum case reminds me of nothing so much as the granuflo case, where a change in inputs had unintended consequences.


There are good reasons to go one way or another with the machine you choose to use, but product integrity shouldn't be one. We live in a world of incredible complexity these aren't cases of malfeasance as much as shit happens, and near as I can tell shit happens everywhere. There needs to be some final quality check at the chair that could pick up some of this but in the end when a dialyzor experiences unexpected results we should suspect a device/process failure.
Title: Re: Sak Recall
Post by: Zach on May 22, 2014, 06:33:51 AM

This aluminum case reminds me of nothing so much as the granuflo case, where a change in inputs had unintended consequences.


As Bill says, shit happens.

There is a new recall for the Fresenius product NaturaLyte® Liquid Bicarbonate Concentrate:
http://finance.yahoo.com/news/voluntary-nationwide-canada-recall-naturalyte-210000427.html

 8)
Title: Re: Sak Recall
Post by: Speedy1wrc on May 22, 2014, 06:34:11 AM
But someone did yell loud enough. My nurse has I think 9 patients now. She is an angel I will add right here and now. She has gone to bat for me with NxStage before and is not afraid to speak up. She saw two of us had elevated aluminum levels a year ago and went through the steps to figure out from where. She isolated it to the two of us using the Pureflow as opposed to the others who had normal aluminum levels using bags. She went to NxStage with that data and was shut down, being told it couldn't possibly be the SAK. We tested my tap water several times as well as the PAK. We involved the dietician to analyze everything I was eating and eliminated any environmental causes.

She now has gone back to NxStage to ask why this occurred since she did in fact bring it up to them.

With the PAK issue, and maybe not even the bad PAK's themselves, but how they handled it opened my eyes. I was on the phone with them daily and their inability to manage the problem was disturbing. Every day I would get another customer support person and inevitably I would be the one informing them that they had a problem. No one internally decided to notify the organization and develop a plan to take care of it. Literally a month into the ordeal I was still speaking to people who had no idea there was a problem. I wrote a letter to th head of their customer experience "department" and it seemed like only then did a memo go out telling everyone in customer support what to do. The fix didn't work, but at least at that point there was there was an acknowledgement that there "was" a a problem. They thought they had fixed the problem, but it still took almost another month of calls to really get them to take it seriously and then actually fix it. But then I spoke to someone trying to get some more bags sent out and that department was utterly surprised that they hadn't heard anything about the problem.

With this new issue it solidifies my feeling that there is a culture of lack of communication. I look at the cycler itself and see some brilliance in some of the design, being an engineer myself, but that was almost 10 years ago that it was designed. The technology is seriously outdated. There are numerous discussions on here of the merits of alternative therapies or methodologies that could improve overall patient outcomes. It seems as if they are sitting back and letting it ride as long as they can.

I have had a lengthy ordeal with defective equipment and all I experienced was, let's just keep throwing replacement machines out. Looking at the FDA incident reports there are over 1500 logged. Most of these are adverse events that have been logged by necessity. How many calls come in to their call center daily? Where I worked, we tracked every call and when there were too many calls coming in it triggered a response to say, what's going on? When products started being difficult to support or too costly, someone would say let's fix this. We have cartridge issues, PAK issues, SAK issues, fistula needle issues, mislabeled bagged dialysate and the only thing I see is blame being laid on external sources. It's not our fault.

I began looking at the 2008@home also. The Davita website now lists it as an option as well as the NxStage . While there are great features of the System 1, ultimately convenience is trumped by health and well being. I am waiting for how NxStage handles this current episode, but I am not waiting long before I decide to stay or leave.
Title: Re: Sak Recall
Post by: Speedy1wrc on May 22, 2014, 07:01:20 AM
With the entire issue of oversized PAK's which I just had another one two days ago that didn't fit
Was it an older lot that didn't get caught or a current lot number?
Title: Re: Sak Recall
Post by: Hemodoc on May 22, 2014, 09:32:39 AM
With the entire issue of oversized PAK's which I just had another one two days ago that didn't fit
Was it an older lot that didn't get caught or a current lot number?

It was probably shipped in March if I remember correctly. The PAKs I got in April fit fine. But yes, I have had mislabeled SAKs as well that said 302 when they were in a 307 sized box. They are failing at the level of post manufacturing quality assurance.

This appears to be a system wide aspect, not just you know what happens. It is above and beyond mistakes and errors. There seems to be a culture of lack of care. For medical devices, that is quite dangerous. NxStage will need step up to the plate and show some real professionalism if they are going to gain my trust back. This especially as Baxter and FMC are on the verge of entering the home hemo market. In addition, it is likely that the Quanta will seek FDA approval if something happens with NxStage market share.  They do not have good timing in "falling asleep at the wheel." This will make their solid market share quite vulnerable at a time when they should instead be taking the lead. Not a good show at all.
Title: Re: Sak Recall
Post by: caregivertech1 on May 22, 2014, 02:10:07 PM
My wife was undoubtedly contaminated with Sak 302 lot 3047913 and/or 3037904 which were NOT on the recall sheet. Her AL level was mid 20's in the 1st week of last July. I used these lot numbers exclusively for 6 weeks prior to the high AL test. The recall sheet showed the very first contaminated Sak we used was treatment on July 29th. Just got off the phone with Nxstage who to their credit called me back 4 days after I asked them to explain. They said if it's not on the list the product was good. There was no answer to my question "Well how do you think she was contaminated?". They were kinda surprised I had the lot numbers then I reminded them we record every lot number each treatment day.....then a silence on the other end. Still think they will eventually fess up with more recalls. Stay tuned.
Title: Re: Sak Recall
Post by: Simon Dog on May 22, 2014, 02:11:24 PM
This especially as Baxter and FMC are on the verge of entering the home hemo market.
The sorbent based systems look very interesting, and could be a game changer.
Title: Re: Sak Recall
Post by: Hemodoc on May 22, 2014, 02:15:52 PM
My wife was undoubtedly contaminated with Sak 302 lot 3047913 and/or 3037904 which were NOT on the recall sheet. Her AL level was mid 20's in the 1st week of last July. I used these lot numbers exclusively for 6 weeks prior to the high AL test. The recall sheet showed the very first contaminated Sak we used was treatment on July 29th. Just got off the phone with Nxstage who to their credit called me back 4 days after I asked them to explain. They said if it's not on the list the product was good. There was no answer to my question "Well how do you think she was contaminated?". They were kinda surprised I had the lot numbers then I reminded them we record every lot number each treatment day.....then a silence on the other end. Still think they will eventually fess up with more recalls. Stay tuned.

I agree, this will be a much larger incident than they are letting on to date.  It is one thing to make mistakes. It is another thing to try and whitewash them once they are uncovered. What is obvious is that they have not yet had full disclosure, nor have the confided which process was in error. We still have not heard what actually happened nor what steps that they have taken to assure nothing like this or worse happens in the future.
Title: Re: Sak Recall
Post by: Speedy1wrc on May 22, 2014, 06:00:30 PM
As suggested, I highly suspect that many more lot numbers are or were involved. I am willing to bet they had a specification for aluminum and were relying on their vendor to ensure it was meeting specification. There is merit to that assumption if it is done properly. More often than not a customer will specify some requirement and the vendor will do their part and test the product to ensure compliance. Then in a duplication of effort the customer will also test the incoming product once again to check for compliance. It is possible to eliminate the incoming inspection as long as the proper safeguards are in place at the source. I think NxStage may have assumed the product met compliance which turned out to be a bad assumption.

I also believe that the lot numbers we were given were possibly the only lot numbers they could find representative samples to test. I have been having issues now for over a year and while some of the SAK's I used were on the list, many were not, yet my aluminum was still high. It seems logical that unless there were supply chain changes mid-stream or process changes, then every lot should resemble every other lot. As mentioned above there has been no disclosure as to the source of the problem nor any indication of what was or is being done to prevent it from happening in the future. We may only be seeing the tip of the iceberg.

NxStage needs to go above and beyond to win back some very cynical customers I think.
Title: Re: Sak Recall
Post by: obsidianom on May 23, 2014, 03:03:35 AM

"The smoking gun has been found."    Notice the DATE.


Rockwell signs dialysate supply contract with NxStage

 March 08, 2013

 KEYWORDS nxstage / Rockwell
 
Email / Print / Reprints /

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Rockwell Medical has signed a two-year contract with NxStage Medical Inc. to manufacture dialysate concentrate for the portable home dialysis machine the NxStage System One.

 "We are pleased to enter into a supply relationship with NxStage, a leader in home hemodialysis," said Rob Chioini, Chairman, CEO and President of Rockwell.
 
Title: Re: Sak Recall
Post by: obsidianom on May 23, 2014, 03:11:58 AM

"The smoking gun has been found."    Notice the DATE.


Rockwell signs dialysate supply contract with NxStage

 March 08, 2013

 KEYWORDS nxstage / Rockwell
 
Email / Print / Reprints /Notice the location .   I knew they were getting the dialysate from down in Texas and Mexico. Here is the culprit.

Rockwell Medical

4051 Freeport Pkwy # 100,
 
Grapevine, TX 76051

(972) 874-2130


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Rockwell Medical has signed a two-year contract with NxStage Medical Inc. to manufacture dialysate concentrate for the portable home dialysis machine the NxStage System One.

 "We are pleased to enter into a supply relationship with NxStage, a leader in home hemodialysis," said Rob Chioini, Chairman, CEO and President of Rockwell.
Title: Re: Sak Recall
Post by: obsidianom on May 23, 2014, 03:18:30 AM

Former Rockwell Medical executive alleges SEC violations

Posted on June 20, 2012 by Chris Carey


The former head of drug development at Rockwell Medical Technologies Inc. (Nasdaq: RMTI) says the company and its chief executive knowingly issued false and misleading press releases and violated other securities laws.
 
Dr. Richard C. Yocum, who was fired from Rockwell Medical in September, alleged in a wrongful termination suit that he was ousted because he repeatedly complained to its chairman and CEO, Robert L. Chioini, about violations of Securities Exchange Commission and Food and Drug Administration rules.
Title: Re: Sak Recall
Post by: obsidianom on May 23, 2014, 04:26:24 AM
Read my previous postes then this.
March 2013 Nxstage signs contract with Rockwell to manufacture dialysate. May 2013 the first contaminated batches start.
Rockwell is accused by doctor on staff of falsifying test results to FDA and SEC. 
Gee folks , you think there is a connection????
Rockwell may be behind a lot of this and Nxstage got into bed with them.
Title: Re: Sak Recall
Post by: caregivertech1 on May 23, 2014, 04:57:31 AM
That might also explain the Mexico connection.
Title: Re: Sak Recall
Post by: obsidianom on May 23, 2014, 05:39:38 AM
It gets better:



Yocum alleged in his suit that Rockwel Medical:
 
–falsely claimed that the results of its earlier Phase IIb studies of SFP were positive, despite the fact that they failed to demonstrate that the treatment was effective.
 
– falsely claimed that the Phase IIb trials produced clear dosing data.
 
– falsely claimed that the company had an agreement with the FDA on the design of its Phase III clinical trials.
 
– proceeded with those trials despite unresolved differences with the FDA, without correcting its public statements and informing investors of those differences.
 
– announced an unrealistic date for bringing SFP to market, disregarding Yocum’s much longer timetable.
 
– failed to modify its Phase III trials to account for changes in FDA product labeling for erythropoiesis-stimulating agents, which are used to treat anemia and would likely be taken by all of the participants in the trials.
Title: Re: Sak Recall
Post by: obsidianom on May 23, 2014, 05:45:12 AM
AND MORE

Yocum’s successor, Dr. Annamaria Kausz, recently left Rockwell Medical after just seven months, adding to the turnover in its clinical-development program. The company provided no explanation for that departure in the press release it issued April 19 to announce the hiring of her replacement. In fact, it didn’t even mention her or say that she had resigned.
 
Sharesleuth also noted that Rockwell Medical took the unusual step last November of extending the life of 400,000 warrants it had issued in the fall of 2008 to a consultant who was later found to have participated in a massive fraud scheme at another public company.
 
That consultant, Michael J. Xirinachs, was one of Rockwell Medical’s co-founders.
Title: Re: Sak Recall
Post by: Speedy1wrc on May 23, 2014, 05:46:41 AM
Google Rockwell Medical DaVita. Apparently they also just jumped into bed with them.
Title: Re: Sak Recall
Post by: obsidianom on May 23, 2014, 05:48:27 AM
AND MORE


The problems began the next month. According to Yocum’s suit, Rockwell Medical learned in February 2010 that its Phase IIb study for SFP failed to meet its primary efficacy target.
 
 “Essentially, except for showing an absence of safety issues, the study was a failure,’’ the complaint said.
 
Yocum said in the suit that he and other experts warned Chioini that the results of the study did not provide enough data on efficacy or dosing to proceed directly to Phase III clinical trials.
 
The company nevertheless issued a press release on Feb. 25, 2010 that was headlined “Rockwell Announces Positive Phase IIb Clinical Data.” The release said the study “met its objective of determining the dosing of SFP for the planned Phase III trials.’’
Title: Re: Sak Recall
Post by: obsidianom on May 23, 2014, 05:54:31 AM
NEW FDA LABELING
 
Yocum said in his suit that he raised concerns in the summer of 2011 about how the Phase III trials might be affected by new dosing guidelines for a type of drug taken by people with chronic kidney disease.
 
Last June, the FDA adopted more conservative dosing guidelines for all erythropoiesis-stimulating agents (ESAs). It said dosing should be reduced or interrupted if hemoglobin levels rose to the vicinity of 11 grams per deciliter.
 
Yocum said in his suit that the randomized treatment stage of Rockwell Medical’s planned Phase III trials permitted no changes in ESA dosing until hemoglobin levels reached 12.5 grams per deciliter.
 
Yocum said that he sent an email to others at the company, summarizing the recommendations of various clinical experts and advocating a change in the trial design to incorporate the new FDA labeling.
 
Yocum said in his suit that Chioini was sharply critical of his actions, calling him “unprofessional and reckless.’’ Yocum added that Chioini stopped consulting with him before issuing press releases and other public statements about the trials.
Title: Re: Sak Recall
Post by: obsidianom on May 23, 2014, 05:56:10 AM
Nxstage and Chioini CEO of Rockwell are in bed together. Real nice.
Title: Re: Sak Recall
Post by: Speedy1wrc on May 23, 2014, 06:30:53 AM
So we are pretty sure we are an expendable route to profit.
Title: Re: Sak Recall
Post by: obsidianom on May 23, 2014, 07:21:22 AM
Rockwell is preparing to launch its FDA approved generic drug Calcitriol, to treat secondary hyperparathyroidism in dialysis patients. Calcitriol (active vitamin D) injection is indicated in the management of hypocalcemia in patients undergoing chronic renal dialysis. It has been shown to significantly reduce elevated parathyroid hormone levels. Reduction of PTH has been shown to result in an improvement in renal osteodystrophy. Rockwell intends to launch Calcitriol once it receives FDA manufacturing approval, addressing an estimated $350M U.S. market.

WATCH OUT!!!!!

Treatment for Anemia Associated with Chronic Renal Failure
Rockwell Medical Submits NDA for Triferic

WIXOM, Mich., March 24, 2014 (GLOBE NEWSWIRE) -- Rockwell Medical, Inc. (Nasdaq:RMTI), a fully-integrated biopharmaceutical company targeting end-stage renal disease (ESRD) and chronic kidney disease (CKD) with innovative products and services for the treatment of iron replacement, secondary hyperparathyroidism and hemodialysis, today announced the submission of a New Drug Application (NDA) to the U.S. Food and Drug Administration (FDA) seeking approval for the marketing and sale of Triferic (soluble ferric pyrophosphate citrate), the Company's late-stage investigational iron-replacement drug for treating iron deficiency in chronic kidney disease patients receiving hemodialysis. The NDA submission is based primarily on the datasets derived from the Triferic Phase 3 registration study program, and includes efficacy and safety data from additional studies.

Title: Re: Sak Recall
Post by: obsidianom on May 23, 2014, 07:36:06 AM
Rockwell is putting everything into this drug that the doctor who sued them claims doesnt work. They are in debt BIG time to make this work . It will screw us as dialysis patiients .




Rockwell Medical said on Tuesday that it has secured $20 million in debt financing from Hercules Technology Growth Capital. Based in Wixom, MI, Rockwell Medical is a biopharmaceutical company that targets end-stage renal disease and chronic kidney disease.
 
PRESS RELEASE
 
WIXOM, MI–(Marketwired – Jun 18, 2013) – Rockwell Medical (NASDAQ: RMTI), a fully-integrated biopharmaceutical company targeting end-stage renal disease (ESRD) and chronic kidney disease (CKD) with innovative products and services for the treatment of iron deficiency, secondary hyperparathyroidism and hemodialysis, announced today that it closed a $20 million debt financing with Hercules Technology Growth Capital, Inc.
 “This $20 million straight-debt financing coupled with our recent $40 million equity financing provides us with sufficient cash to get SFP to commercial launch,” stated Rob Chioini, Founder, Chairman and CEO of Rockwell Medical. “We are on schedule to release Phase 3 efficacy data for CRUISE-1 and look forward to those study results.”
 Hercules Technology Growth Capital, Inc. is the leading specialty finance company focused on providing senior secured loans to venture capital-backed companies in technology-related markets, including technology, biotechnology, life science and cleantech industries at all stages of development. Since inception (December 2003), Hercules has committed more than $3.6 billion to over 230 companies.
 The CRUISE Studies
 Rockwell is conducting two pivotal Phase 3 efficacy studies called CRUISE-1 and CRUISE-2. Each study is a prospective, randomized, placebo-controlled, multicenter study to demonstrate efficacy and safety of SFP-iron, delivered via dialysate, in adult CKD patients requiring hemodialysis. Each study comprises approximately 300 patients, randomized equally between SFP and placebo groups with a treatment period of up to 12 months. The primary efficacy end-point for both studies is the mean change in hemoglobin from baseline.
 
Title: Re: Sak Recall
Post by: obsidianom on May 23, 2014, 07:53:46 AM
Notice the timeline. Nxstage signed with Rockwell in March 2013 and then in APRIL 2013 WHEN THEY STARTED MANUFACTURING IT WAS CONTAMINATED.

The affected products and lots can be found in Attachment A.
The affected lots were manufactured between April 2013 and February 2014.
Title: Re: Sak Recall
Post by: Speedy1wrc on May 23, 2014, 09:55:21 AM
So I decided why not...

I just called Rockwell to inquire about the recall. At first they didn't know anything about it. Then they directed me to NxStage. I told the agent they had not been forthcoming about any details so I and other patients had taken upon ourselves to find out what we could. She took my name and is referring it to quality control. She told me I should expect a call possibley Tuesday.

Failing at that approach I called NxStage's Senior Director of Customer Experience. All I got was a voicemail, so I am waiting to see what kind of response I get.
Title: Re: Sak Recall
Post by: Hemodoc on May 23, 2014, 10:10:03 AM
 Speedy, the dates of Rockwell's involvement need to line up with your onset of symptoms in late February or March 2013. If there product was not involved until May, then that doesn't explain your earlier involvement.

We need more information before we can draw clarity on this.
Title: Re: Sak Recall
Post by: Simon Dog on May 23, 2014, 11:08:21 AM
Quote
I am willing to bet they had a specification for aluminum and were relying on their vendor to ensure it was meeting specification.

I believe that every batch of beer is tested for alcohol content before shipment, and I expect Jack Daniels does some quality control before it bottles its stuff.   It would seem to make sense to test the lots of solution for conformance to spec before packagiing them.
Title: Re: Sak Recall
Post by: Speedy1wrc on May 23, 2014, 01:01:49 PM
Speedy, the dates of Rockwell's involvement need to line up with your onset of symptoms in late February or March 2013. If there product was not involved until May, then that doesn't explain your earlier involvement.

We need more information before we can draw clarity on this.
Agreed, and by calling I wanted to see what they had to say. They could easily say they did what they were expected to do. But we all have a lot of questions and right now few answers. It's time to get answers.
Title: Re: Sak Recall
Post by: Speedy1wrc on May 23, 2014, 01:04:29 PM
Quote
I am willing to bet they had a specification for aluminum and were relying on their vendor to ensure it was meeting specification.

I believe that every batch of beer is tested for alcohol content before shipment, and I expect Jack Daniels does some quality control before it bottles its stuff.   It would seem to make sense to test the lots of solution for conformance to spec before packagiing them.
I agree wholeheartedly! Everything they ship out the door should be tested as thoroughly as possible and then some.
Title: Re: Sak Recall
Post by: Hemodoc on May 23, 2014, 01:18:17 PM
Speedy, the dates of Rockwell's involvement need to line up with your onset of symptoms in late February or March 2013. If there product was not involved until May, then that doesn't explain your earlier involvement.

We need more information before we can draw clarity on this.
Agreed, and by calling I wanted to see what they had to say. They could easily say they did what they were expected to do. But we all have a lot of questions and right now few answers. It's time to get answers.

Absolutely and it is NxStage that owes us that explanation.
Title: Re: Sak Recall
Post by: obsidianom on May 23, 2014, 01:54:57 PM
My wife had 11 contaminated cases.  Nxstage just admitted it to us.
Last fall after 6 of them she had trouble walking for 2 months and I had to hold her everwhere she went . I couldnt leave her alone . It scared the hell out of us as we didnt know why. Now we do.
Title: Re: Sak Recall
Post by: PrimeTimer on May 23, 2014, 10:13:19 PM
Idea: In addition to treatment logsheets, I like to keep the receipts of the delivery invoices from NxStage...they include Lot Numbers on them. For some reason the delivery drivers they contract with didn't have a copy to give me this past month but, luckily I still had a copy I could print out from their email notifying me of delivery date/time.
Title: Re: Sak Recall
Post by: obsidianom on May 24, 2014, 03:40:51 AM
NXSTAGE

NXTM » Topics » Manufacturing

These excerpts taken from the NXTM 10-K filed Mar 16, 2009.

Manufacturing


 The manufacture of our products is accomplished through a complementary combination of outsourcing and internal production. Specifically, we manufacture our System One Cycler and some PureFlow SL hardware, and assemble, package and label our PureFlow SL disposables within our facility in Fresnillo, Mexico. We manufacture components used in our System One cartridge assembly, and assemble the System One disposable cartridge and some blood tubing sets, Medics and transducer protectors in our facility in Tijuana, Mexico. We manufacture our dialyzers in our Rosdorf, Germany facility. We outsource the manufacture of premixed dialysate, needles, some blood tubing sets and some PureFlow SL hardware.
 
 

 We have a molding facility in Modena, Italy, which molds components used in the products we manufacture ourselves in Tijuana, Mexico, as well as supplies the molded components for finished goods manufactured by Kawasumi Laboratories, Inc., or Kawasumi, as described below.
 
 

 We have single-source suppliers of components, but in most instances there are alternative sources of supply available. Where obtaining a second source is more difficult, we have tried to establish supply agreements that better protect our continuity of supply. These agreements, currently in place with several key suppliers, are intended to establish commitments to supply product. We do not have supply agreements in place with all of our single-source suppliers.
 
 

 We have certain agreements that grant certain suppliers exclusive or semi-exclusive supply rights. We contract for the manufacture of the majority of our finished goods of ReadySet blood tubing sets and all our needles from Kawasumi, headquartered in Tokyo, Japan, with manufacturing facilities in Thailand. The current agreement with Kawasumi for the manufacture of blood tubing sets expires in January 2010. Under the terms of this agreement, we supply Kawasumi with molded component parts and Kawasumi in turn uses these components to manufacture finished goods blood tubing sets, which are then purchased by us. We have committed to purchase from Kawasumi a minimum quantity of blood tubing sets over the term of the agreement. We believe that this minimum purchase commitment is less than our anticipated requirements for blood tubing sets.
 
 

 We also have an agreement with Kawasumi for the manufacture of needle sets. Virtually all of these needle sets rely on our patented guarded needle set technology. In February 2007, we agreed with Kawasumi to extend their needle set supply agreement through February 2011. We have committed to purchase from Kawasumi a minimum quantity of needle sets over the three-year extended term of the contract. We believe that this minimum purchase commitment is less than our anticipated requirements for needles.
 
 

 In January 2007, we entered into a long-term supply agreement with Membrana pursuant to which Membrana has agreed to supply, on an exclusive basis for a period of ten years, the capillary membranes that we use in the filters used with the System One for ten years. Membrana has agreed to pricing reductions based on volumes ordered and we have agreed to purchase a base amount of membranes per year. The agreement may be terminated upon a material breach, generally following a sixty day cure period.
 
 

 We purchase bicarbonate-based premixed dialysate from B. Braun Medizintechnologie GmbH, or B. Braun, and our lactate-based premixed dialysate from Laboratorios PISA, or PISA. We have a supply agreement with B. Braun that obligates B. Braun to supply the dialysate to us through 2009 in exchange for a minimum purchase commitment, which we believe is less than our anticipated requirements. The contract may be terminated upon a material breach, generally following a 30-day cure period. Our supply agreement with PISA terminated at the end of 2008. We are currently purchasing products from PISA on a purchase order basis as we negotiate a new agreement with PISA.
Title: Re: Sak Recall
Post by: obsidianom on May 24, 2014, 03:48:55 AM

March 8, 2013

Rockwell Medical Signs Supply Contract With NxStage(R) Medical

WIXOM, MI -- (Marketwire) -- 03/08/13 -- Rockwell Medical (NASDAQ: RMTI), a fully-integrated biopharmaceutical company targeting end-stage renal disease (ESRD) and chronic kidney disease (CKD) with innovative products and services for the treatment of iron deficiency, secondary hyperparathyroidism and hemodialysis, announced that it has signed a contract with NxStage® Medical, Inc. to manufacture dialysate concentrate for the NxStage System One™, the first and only truly portable hemodialysis system cleared for home use by the U.S. Food & Drug Administration. The contract term is for two years.
 
Title: Re: Sak Recall
Post by: obsidianom on May 24, 2014, 03:50:02 AM

March 8, 2013

Rockwell Medical Signs Supply Contract With NxStage(R) Medical

WIXOM, MI -- (Marketwire) -- 03/08/13 -- Rockwell Medical (NASDAQ: RMTI), a fully-integrated biopharmaceutical company targeting end-stage renal disease (ESRD) and chronic kidney disease (CKD) with innovative products and services for the treatment of iron deficiency, secondary hyperparathyroidism and hemodialysis, announced that it has signed a contract with NxStage® Medical, Inc. to manufacture dialysate concentrate for the NxStage System One™, the first and only truly portable hemodialysis system cleared for home use by the U.S. Food & Drug Administration. The contract term is for two years.
Thi is the date of announcement only. They could have started much earlier!!!

The premix solution is made in Italy at lab PISA . This was found in SEC filing p51 of 121

They have maufacturing facilities in Mexico, Italy, and Germany
Title: Re: Sak Recall
Post by: obsidianom on May 24, 2014, 06:36:26 AM
I read the whole 121 page annual report from Nxstage for 2013 . They curiously dont mention the Pureflow system or the concentrated dialysate. They do outsource a lot . They get the premixed dialysate from Italy through a contract outsource.   
They have facilities in Mexico , Italy and Germany. In GERMANY they make the dialyzers for themselves and Asahi corp. In Mexico a lot of the system is built. They seem to have 2 locations in Mexico.
They were sued by Gambro in Massachusets court in 2012 and settled out of court in 2014.
I still think it is Rockwell making the dialysate but it is curious they dont make any mention of that part of the system anywhere in the annual report. They make it sound like it is all premixed dialysate.
 
Here is a thought . Perhaps they left the Pureflow out of the annual report BECAUSE THEY KNEW LONG BEFORE THIS THAT THERE WAS A PROBLEM WITH THE DIALYSATE.  They signed off the annual report on 3-3-13.  That means they left out a major ccomponent of the system in the report ,only wrtiting about the premixed dialysate, because PERHAPS they knew there was a problem in 2013 or very early 2014. Long before they admitted it.
I read ther report twice through the best I could . I couldnt find ANYTHING about Pureflow or dialysate concentrate. Only premixed dialysate.

Lawsuit gambro
http://dockets.justia.com/docket/massachusetts/madce/1:2012cv10370/142392
Title: Re: Sak Recall
Post by: obsidianom on May 24, 2014, 07:11:48 AM
Immediate Past CMS Chief Medical Officer Joins NxStage Board

Former Centers for Medicare & Medicaid Services (CMS) Chief Medical Officer Barry M. Straube, MD, joined NxStage Medical's Board of Directors, the company announced in July. Dr. Straube, who also directed CMS's Office of Clinical Standards & Quality, retired from the agency in February 2011.

While at CMS, Dr. Straube and his office spearheaded several key initiatives, including national quality improvement collaboratives, quality measurement and information technology efforts, the development of value-based purchasing models, and implementation of the Affordable Care Act, NxStage noted in a news release. Dr. Straube also chaired the End-Stage Renal Disease (ESRD) and Clinical Laboratory Open Door Forum and acted as a senior advisor to the agency on issues related to ESRD and transplantation.

NxStage's System One is a portable hemodialysis system cleared for home use by the Food & Drug Administration.

© 2011 Lippincott Williams & Wilkins, Inc.


Investment in NxStage Medical
 Further strengthening of strategic alliance

May 9, 2012
 Asahi Kasei Medical Co., Ltd.

Asahi Kasei Medical and NxStage Medical, Inc. of the US have concluded an agreement to further strengthen their strategic alliance in the field of hemodialysis which began in May 2009. As part of the reinforcement of the strategic alliance, Asahi Kasei Medical has taken an ownership stake in NxStage Medical through the conversion of all outstanding principal and interest of a loan to NxStage Medical into newly issued shares.
 
In May 2009, Asahi Kasei Medical provided a four-year loan of US$40 million to NxStage Medical as part of their strategic alliance. All outstanding principal and interest of this loan has been converted to shares of NxStage Medical, as follows.

 
Title: Re: Sak Recall
Post by: obsidianom on May 24, 2014, 08:24:52 AM
I have found out that the only way to really get high blood aluminum levels is through direct membrane (dialysis membrane) to blood contact. I was also informed that GI absobtion is virtually nill so it shoudnt occur just through drinking water or aluminum containing products. It really has to be non GI. as the gut is a good filter for aluminum. Anybody with high aluminum levels has to assume it is through blood contact such as dialysis. So when the aluminum rises in a patient we are wasting our time looking for oral sources. ----Think dialysis.
Title: Re: Sak Recall
Post by: obsidianom on May 24, 2014, 10:11:38 AM
http://www.compliance-alliance.com/wp-content/uploads/2010/11/Establishment-Inspection-Report-for-Rockwell-Medical-Technologies-Inc.-manufacturer-of-Dialysate-Concentrates.pdf

Everyone should go to this link to see the MAJOR violations at the Rockwell plant in SC making DIALYSATE. This is SCARY as they had numerous violations and the customer complained. The CEO is the same guy that NXSTAGE signed the contract with.
This is another smoking GUN.
Title: Re: Sak Recall
Post by: Hemodoc on May 24, 2014, 11:49:25 AM
Good posts. It still is needful for NxStage to provide full disclosure of all events. That is their duty to all of their patients. We have yet to hear the full story and it should come from them. Sadly, I believe that they just want to whitewash this serious event and keep going. After all that is the manner of American Dialysis companies. It looks like NxStage is just joining the big boys in this reqard.
Title: Re: Sak Recall
Post by: slipkid on May 24, 2014, 11:50:22 AM
I meet with my neph and Davita team yesterday.  My aluminum level drawn a week ago had risen from 18 micrograms per liter in January 2014 to 26 micrograms per liter. This is a 75 percent increase over January and is 189 percent above Davita's maximum permissible level for aluminum.

My water samples for tap and Pureflow water for aluminum were recorded as less than 1 part per billion.  Conclusively, the aluminum is coming from the dialysate.

My neph, who has 50 years experience in renal care, related tales of aluminum poisoning (his words) in South Africa in the 1970s.  He claimed the levels of exposure were much higher than reported in the instant case.  He ignored my complaints except for the evidence of muscle twitching. He had me walk up and down the hall and said I was fine (I was not).  I concluded he was living in the past and not up to date with current studies on aluminum exposure at the levels patients are reporting.

I asked what was Davita's position on the issue of aluminum in the dialysate.  He said he would speak to Davita's chief medical officer about it, and the use of a chelatian agent (deferoxamine) to clean me out.

He asked me WHAT I WANTED TO DO. He suggested I could go back to clinic on an every other day schedule, but I rejected that as I gained 50-60  pounds during my 7 years of clinic dialysis.  Since taking control of my dialysis 18 months ago I have lost half that weight gain.

I decided to abandon the Pureflow and use the premixed bag dialysate although I have no information on the aluminum levels in the premixed bags.

I am now ready to take action with a couple of entities that have expressed interest in the aluminum contamination crisis.

More to come at a later date.









Title: Re: Sak Recall
Post by: obsidianom on May 24, 2014, 01:04:48 PM
As far as I know the premixed dialysate is made in Italy while the SAKS are from Rockwell . So you are probably ok on the premix.
Title: Re: Sak Recall
Post by: Hemodoc on May 24, 2014, 01:58:10 PM
Find a renowned toxicologist at the nearest medical school. I am not sure you need chelation at this point since there are side effects of chelation, but I would seek the advice of a toxicologist.
Title: Re: Sak Recall
Post by: slipkid on May 24, 2014, 04:11:56 PM
Nothing local, nearest city is Phoenix.  Also, a federally licensed, metals toxicology lab there as well.
Title: Re: Sak Recall
Post by: Speedy1wrc on May 24, 2014, 07:15:52 PM
I just dumped a bunch of leaky bags today and the labels said they were made in Mexico. I am not certain the bags are any better, possibly as bad or worse. With the PAK issue I had been on bags for almost a month concluding maybe 2 weeks ago. My aluminum which was drawn on the 15th had risen to 20. I did use a known(after the fact) SAK just prior to the draw so that possibly could have been a major contributor.

On the Rockwell website they claim their manufacturing facilities are in the United States. I plan on asking them when and if they return my call.

I noted some symptoms mentioned above. I hadn't connected them to the aluminum till now but it is making more and more sense.

As far back as last year I have had the metallic taste in my mouth. I have had several surgeries for sleep apnea but still have had odd symptoms which my ENT Dr can't explain. I have difficulty swallowing and we have attributed it to a lack of saliva. My mouth dries out and my nose is always very dry. I also spend a lot of time itching my calves. So much so I have sores on my lower legs. Being Winter we assumed it was the dry air, now that it is Spring, I still have it and going back on the SAK's a couple weeks ago, it has gotten much worse. Muscle strength. For the last year I have struggled with any sort of physical activity. I am constantly off balance and I tire easily. A little over a month ago I fell and ended up with a concussion. Two weeks after that I fell face first and banged myself up pretty good. My appetite is horrid. My dietician has been baffled. I sometimes go all day without eating because I can't. When I do eat, after a few bites I feel awful. I can't remember anything. The other day my girlfriend and I went to a garage sale nearby. We took a different route there and back. My girlfriend asked why, and I told her I saw a sign for a sale on a road next to ours. We have lived there over 5 years and I am from this area. I couldn't remember the name of the road one block down from our house. I am constantly forgetting appointments. Completely forgetting, not just having them slip my mind. People are always telling me things I should know and it's as I I never heard it. The one that caught my eye above was muscle twitches. This has been something that started maybe 6 mos. ago. Insomnia notwithstanding the twitches drive me nuts. I can't even attempt to sleep without Gabapentin to make the twitches stop. The side effects are not fun though. There is so much pain on both my index fingers that there aremdays I simply can't use them. I am certainly not old enough for arthritis and the onset has been very rapid. Most days I can't get down on the floor to do any sort of work knowing that I can't get back up. My knees are in horrific pain.  It has come about within the last 6 to 9 mos. My teeth are also starting to deteriorate rapidly.. The edges are getting all pitted and wearing away. Again this has been a recent occurance with no other known cause.

I had initially thought I had only  a few symptoms but after hearing from everyone I think I have a lot more ailments related to the aluminum than I had originally believed. My girlfriend and I have been discussing the symptoms and she hasn't said anything but tonight admitted she had noticed a change in me. She has noticed me grabbing onto counters in the kitchen to steady myself or catch myself to keep from falling. Being a nerdy engineer she has noticed I haven't been as sharp as usual. I always have the answer, but more recently I stumble over my words and I struggle trying to help my daughter with her math homework. Math is my thing and I am frustrated when I get lost on simple problems.

This is much worse than I suspected. We are finding a lot of dirt and tying symptoms to the aluminum. This is getting bad.
Title: Re: Sak Recall
Post by: PrimeTimer on May 25, 2014, 12:33:06 AM
My nurse just called me at work 1/2 hour ago to tell me to text her my SAKs lot numbers when I get home.  I know for sure that I'm using 401 and have to drain my Pure Flow tonight.  I'm glad this is my off night.  No wonder I felt confused most of the time, a little agitated, and some muscle rigidity.  DaVita is slacking up.... Praise God that they discover this problem.   :o
My husband has only been doing home hemo for 6 months using Pureflow SAKS. We don't have any of the bad SAKS but he has been feeling confused and agitated lately. He has high blood pressure so the smallest amount of stress makes it worse. Our Fresenius center called right away about the recall, so that was good but still, makes us feel a little nervous about the whole thing. His BP hasn't been too bad the past couple nites tho...we discovered the MC (Music Choice) channel on our TV and love listening to oldies but goldies, 70's rock and swing, livens up treatment sessions for us and gets our minds off all this stress. I've read a lot of your posts and think you are a strong person and have a good attitude. Hope some of that rubs off on me, too! Thanks for being an inspiration!!  :beer1;
Title: Re: Sak Recall
Post by: obsidianom on May 25, 2014, 03:23:37 AM
I just dumped a bunch of leaky bags today and the labels said they were made in Mexico. I am not certain the bags are any better, possibly as bad or worse. With the PAK issue I had been on bags for almost a month concluding maybe 2 weeks ago. My aluminum which was drawn on the 15th had risen to 20. I did use a known(after the fact) SAK just prior to the draw so that possibly could have been a major contributor.

On the Rockwell website they claim their manufacturing facilities are in the United States. I plan on asking them when and if they return my call.

I noted some symptoms mentioned above. I hadn't connected them to the aluminum till now but it is making more and more sense.

As far back as last year I have had the metallic taste in my mouth. I have had several surgeries for sleep apnea but still have had odd symptoms which my ENT Dr can't explain. I have difficulty swallowing and we have attributed it to a lack of saliva. My mouth dries out and my nose is always very dry. I also spend a lot of time itching my calves. So much so I have sores on my lower legs. Being Winter we assumed it was the dry air, now that it is Spring, I still have it and going back on the SAK's a couple weeks ago, it has gotten much worse. Muscle strength. For the last year I have struggled with any sort of physical activity. I am constantly off balance and I tire easily. A little over a month ago I fell and ended up with a concussion. Two weeks after that I fell face first and banged myself up pretty good. My appetite is horrid. My dietician has been baffled. I sometimes go all day without eating because I can't. When I do eat, after a few bites I feel awful. I can't remember anything. The other day my girlfriend and I went to a garage sale nearby. We took a different route there and back. My girlfriend asked why, and I told her I saw a sign for a sale on a road next to ours. We have lived there over 5 years and I am from this area. I couldn't remember the name of the road one block down from our house. I am constantly forgetting appointments. Completely forgetting, not just having them slip my mind. People are always telling me things I should know and it's as I I never heard it. The one that caught my eye above was muscle twitches. This has been something that started maybe 6 mos. ago. Insomnia notwithstanding the twitches drive me nuts. I can't even attempt to sleep without Gabapentin to make the twitches stop. The side effects are not fun though. There is so much pain on both my index fingers that there aremdays I simply can't use them. I am certainly not old enough for arthritis and the onset has been very rapid. Most days I can't get down on the floor to do any sort of work knowing that I can't get back up. My knees are in horrific pain.  It has come about within the last 6 to 9 mos. My teeth are also starting to deteriorate rapidly.. The edges are getting all pitted and wearing away. Again this has been a recent occurance with no other known cause.

I had initially thought I had only  a few symptoms but after hearing from everyone I think I have a lot more ailments related to the aluminum than I had originally believed. My girlfriend and I have been discussing the symptoms and she hasn't said anything but tonight admitted she had noticed a change in me. She has noticed me grabbing onto counters in the kitchen to steady myself or catch myself to keep from falling. Being a nerdy engineer she has noticed I haven't been as sharp as usual. I always have the answer, but more recently I stumble over my words and I struggle trying to help my daughter with her math homework. Math is my thing and I am frustrated when I get lost on simple problems.

This is much worse than I suspected. We are finding a lot of dirt and tying symptoms to the aluminum. This is getting bad.
What is your calcium level?? Some of those symptome may be from hypercalcemia which can occur from high aluminum. Also check your magnesium as that can also do it.
Title: Re: Sak Recall
Post by: Speedy1wrc on May 25, 2014, 07:44:38 AM
Calcium is 9.0, magnesium isn't reported on my last set of labs.

I forgot to add....gas. It's nasty bad. Even when I am sleeping.
Title: Re: Sak Recall
Post by: obsidianom on May 25, 2014, 08:41:20 AM
NXstage just changed all this .Read this abstract. Aluminum wasnt an issue until NOW

Am J Kidney Dis. 2005 Aug;46(2):316-9.

Frequency of elevated serum aluminum levels in adult dialysis patients.

Jaffe JA1, Liftman C, Glickman JD.

Abstract

BACKGROUND:

Aluminum toxicity, a complication described in dialysis patients exposed to aluminum-containing phosphate binders or water used in dialysate preparations containing elevated levels of aluminum, can cause significant morbidity. Although physicians monitor patient aluminum levels, the frequency of abnormal aluminum levels has not been reported.

METHODS:

We retrospectively examined 1,410 measurements of serum aluminum in 207 dialysis patients at the Franklin Dialysis Center (FDC; Philadelphia, PA) from January 1, 2000, through April 3, 2003. We also surveyed serum aluminum levels from a nationwide dialysis provider (DaVita) to more than 43,000 patients. Local dialysis facilities were surveyed to determine the annual frequency of aluminum testing in their patients.

RESULTS:

Of 1,410 serum aluminum measurements performed at FDC, only 30 abnormal levels (2.1%) were found. DaVita measured approximately 117,000 aluminum levels annually during the last 3 years, of which 2.5% were abnormal. Frequencies of abnormal aluminum levels declined significantly each year at FDC and DaVita.

CONCLUSION:

The current frequency of abnormal aluminum levels in our dialysis facility and a national dialysis provider is extremely low and has significantly declined.
Title: Re: Sak Recall
Post by: Speedy1wrc on May 25, 2014, 09:26:53 AM
Profit then does not equal profit now.

Dialysis suppliers, providers, and clinics were used to large profit margins. Now they need to cut corners to make money. Just look at the Davita EPO scandal.

I think there are due to be big changes to the industry. Things certainly can't remain the same.
Title: Re: Sak Recall
Post by: KarenInWA on May 25, 2014, 04:59:19 PM
I am not currently on dialysis, but I have been watching this thread with great interest. I have always looked at NxStage as the be all end all for dialysis treatment. I was on in-center HD for 7 months back in 2011 before receiving a live donor transplant. I would have looked into using NxStage had my tx not happened.

What I want to know is this - why is the only concern being expressed on this site? I belong to many kidney groups on Facebook, and can't even really find anything in the NxstageUsers group. Is this weird? Why is no one else concerned? I for one am really bothered by all of this, because if I ever need to go back on dialysis, I don't know what I will do. I really don't want to do PD, because I don't like the amount of time it takes. If I do HHD, NxStage is the only thing that can fit in my home.

Any thoughts as to why other dialysis communities don't seem to be as concerned about all of this?

KarenInWA
Title: Re: Sak Recall
Post by: Hemodoc on May 25, 2014, 06:24:20 PM
I am not currently on dialysis, but I have been watching this thread with great interest. I have always looked at NxStage as the be all end all for dialysis treatment. I was on in-center HD for 7 months back in 2011 before receiving a live donor transplant. I would have looked into using NxStage had my tx not happened.

What I want to know is this - why is the only concern being expressed on this site? I belong to many kidney groups on Facebook, and can't even really find anything in the NxstageUsers group. Is this weird? Why is no one else concerned? I for one am really bothered by all of this, because if I ever need to go back on dialysis, I don't know what I will do. I really don't want to do PD, because I don't like the amount of time it takes. If I do HHD, NxStage is the only thing that can fit in my home.

Any thoughts as to why other dialysis communities don't seem to be as concerned about all of this?

KarenInWA

NxStage users now called  Home Dialysis United has had commercial support from NxStage for their conferences and a VERY close working relationship with them through Rich Berkowitz and Joe Turk at NxStage. I am not surprised that they are silent on the issue, but I doubt that Rich would have been silent. He always spoke out against anyone anywhere that endangered dialysis patients.

 HDC likewise has industry support. I place a post on Dialysis Discussions Unlimited but it didn't last long.

Renal support network has huge ties to the industry.

RenalWeb sells ads to NxStage and Medisystems. They have not gone as far as they should have to date either.
AAKP, NKF, RPA are all industry supported.

That is one of the reasons why IHD is such an important site. However, I would venture to state we have not yet heard the end of this. There is much more to this story to come and hopefully soon. Dr. O has done a great job looking into some of the connections. I am waiting to hear from NxStage and to see how they respond now and in the future. If they go into whitewash mode, then my relationship as a patient and advocate will be over.

The Baxter machine is NOT portable, but has some very interesting features. It is likely the next one on the market. If NxStage wants my support, it is important for them to take a leadership role in this whole mess and set things straight and in complete transparency. To date, they have not given us the details on the who, what when and where in the process this event occurred.

If they choose to hide behind their statements in the voluntary recall which has not declared all of the lots since many had symptoms and elevations of aluminum BEFORE the reported April 2013 notifications, then I would not be least bit surprised if someone else digs up the real story to their embarrassment even further.

NxStage is a direct competitor of FMC/DaVita and other although they are in agreements with them for the home market. It will not take too much to get their competitors to open up on NxStage especially given that FMC has it's own portable machine in development and pending FDA approval. 

In any case, it is up to NxStage to take the bull by the horns or sit back and let someone else do it for them. The first way will indeed be painful, but could save their reputation. JFK faced the end of his presidency with the CIA led Bay of Pigs invasion. I am convinced that JFK was not really on the inside of that operation and it was just forced upon him by an out of control CIA. However, JFK stood up, took full responsibility and is one of the aspects of his presidency that he did well in my opinion.

I believe that is what NxStage needs to do in toto.  Will they? We shall wait and see. That will give us all the message of whether they are going to truly be the dialysis advocate that they have portrayed their company, or whether they are just another business as usual for-profit dialysis corporation. Time will tell us soon which one they are.
Title: Re: Sak Recall
Post by: obsidianom on May 26, 2014, 05:44:20 AM
My wife is stiiting next to me hooked up to the Nxstage machine as I write this. For the first time in 2 years I am uncomfortable with it.
My wife put it perfectly when i hooked her up and she said to me " I dont anymore if while I am on this machine I am being helped or HARMED."
That really hit me. WE both used to feel safe on it.
Its like being married and having your spouse have an affair. You can never trust them again. (at least I wouldnt)  . Trust has been lost now. How can we ever trust Nxstage again?.  They have violated our trust and not handled it well in the aftermath. They really didnt even apologize. It was more of a "well we made a little mistake but dont worry about it and try to forget it and move on" .   I would expect a lot more after what occurred but so far they havent been very contrite.  They want our trust but did nothing so far to earn it back.
Yes the aluminum is an issue. BUT THE FAR BIGGER ISSUE IS TRUST, AND FUTURE FAITH IN THEM TO MAKE A SAFE PRODUCT.  How do we ever trust them again. This time it was aluminum. Next time it could be endotoxin or other poisons like cyanide (that was noted in the Rockwell violation, lack of testing for cyanide). Or just simply not having the correct levels of the chemicals that are supposed to be in there such as potassium and sodium and calcium etc.
Their quality control is highly suspect so HOW DO WE TRUST WHAT WE ARE GETTING NOW ?
Well I put this out to Nxstage . You need to win back our trust folks. I suggest you get to it NOW!!
Title: Re: Sak Recall
Post by: obsidianom on May 26, 2014, 07:31:12 AM
Please read my thread on General discussion  PLEASE READ , BY DR. O.
I have added several new posts that are interesting . Rockwell is all over and working with Nxstage.   
I hadnt realized that Rockwell acttually produces the raw acid and bicarbonate for Fresenius and Davita. They are HUGE.  They tested Triferic on in center patients in the dialysate and when it is finally approved will have it put in the dialysate in center to many patients.   Remember their filthy violation filled plant in SC.  They are more scary then Nxstage . Of course now Nxstage is in bed with them. WOOOPEEEE!!!!
Title: Re: Sak Recall
Post by: MooseMom on May 26, 2014, 08:16:20 AM
I was about to post the same sentiments shared by Karen.  I had gone so far as to redesign and adapt my entire basement for NxStage equipment and supplies as, after years of research, this was the modality that I'd chosen for myself.

I'd always believed that NxStage were the "good guys" in an industry where "good guys" are few and far between.

I've been following this thread for many days and am really disappointed that the news seems to be worsening.

I agree with everyone that trust has been violated, and if you can't trust the various people who are supposed to be working to help you survive this devastating illness, weel, it's devastating.

Title: Re: Sak Recall
Post by: Simon Dog on May 26, 2014, 10:45:44 AM
What is lacking, and would help, is a commitment from NxStage that all future batches will be chemically analyzed to make sure that all parameters are within specification.   In other works, quality control at the Jack Daniels level.
Title: Re: Sak Recall
Post by: Speedy1wrc on May 26, 2014, 01:16:53 PM
NxStage's silence is deafening.
Title: Re: Sak Recall
Post by: obsidianom on May 26, 2014, 01:47:22 PM
On the 8th day God created EPO. On the 9th day Rockwell created Triferic to replace it.  On the 10 th day the patients became anemic again. oops!
Title: Re: Sak Recall
Post by: Hemodoc on May 26, 2014, 02:19:20 PM
 For future reference, oral absorption of Aluminum almost NEVER takes place. It is by direct membrane contact from a water source. The aluminum binders were the scapegoat back in the 80's for aluiminum caused dementia, however, at that time they were not using RO systems. In the fallout of that report, aluminum binders took the hit and then folks were placed on calcium binders which increased the risk of heart disease and cardiovascular calcification.

Here is a VERY interesting article revieiwing this issue:

http://www.biomedcentral.com/1471-2369/12/20

One aspect that is terribly troubling fromt his article is that because the aluminum becomes protein bound, the levels in the patient are 3-4 fold HIGHER than in the contaminated fluids. We have much left to learn about this entire debacle.
Title: Re: Sak Recall
Post by: caregivertech1 on May 26, 2014, 03:18:13 PM
The next step will be how to remove the aluminum. As I mentioned in an earlier post my wife went incenter(FMC) twice to do that. The first time, with a level of 25, we were on the F200 dialyzer which filtrates larger molecules 3 times a week for 3 weeks. We went back home with a level of 12 which is still high. At home we went back to 28 (don't know for sure yet about the lot numbers). So we went back in the center with the F180 dialyzer for another 3 weeks. This time we went back home with a level of 10. At home we trained on the cartridge 124-C which is packaged without a dialyzer. This is a real bear to prepare. You hang 3 saline bags and install your own dialyzer..in our case the F180. After 6 days the AL was 17 and at the end of about 3 weeks it was 20. The very day we ended this test NxStage fessed up with the recall with affected lot numbers.....You guessed it, the 124-C with the F180 test was run with a contaminated SAKs. Thanks NxStage for sitting on this info while we working like hell to remove the AL. I tested this batch (and the PAK H2O)used before the letter came out. A NxStage rep and my center came to our home and tested it again after the letter came out. No results yet. The samples went to 2 labs. Not sure the current cartridge(170-C with attached dialyzer) will remove this AL. As another post indicated the AL combines with protein which is probably larger than the middle molecules they advertise can be removed. So now we're back to the 124-c for a week now with a starting level of 20 and hopefully non contaminated SAKS(who the hell knows). We'll sample again in 2 weeks. Stay tuned.
Title: Re: Sak Recall
Post by: Zach on May 26, 2014, 03:34:46 PM

What I want to know is this - why is the only concern being expressed on this site? I belong to many kidney groups on Facebook, and can't even really find anything in the NxstageUsers group. Is this weird? Why is no one else concerned? I for one am really bothered by all of this, because if I ever need to go back on dialysis, I don't know what I will do. I really don't want to do PD, because I don't like the amount of time it takes. If I do HHD, NxStage is the only thing that can fit in my home.

Any thoughts as to why other dialysis communities don't seem to be as concerned about all of this?

KarenInWA

The recall is mentioned on the Facebook page of NxStageUsers:
https://www.facebook.com/groups/nxstageusers/

It's just that most of the comments were made around May 15th-17th.
And Facebook keeps moving postings and comments down the timeline as newer topics are posted.

Here is Bill's posting:
Bill Peckham
May 15 at 5:07pm · Seattle, WA
There has been excess aluminum in some SACs manufactured in the last year, There was a recall announced today, check with your unit for effected SAC numbers. Everyone should get their Aluminum checked
~~~~~~~~~~

You'll see lots of posts and comments below Bill's post.

Here is Hemodoc's post on the Facebook page for Dialysis Discussion Uncensored:
https://www.facebook.com/groups/DialysisUncensored/


Peter Laird
May 15 at 12:59pm
Everyone on NxStage at home using the PureFlow should contact NxStage and their centers. There is a voluntary recall of PureFlow due to high aluminum levels. Mine have been elevated for the last 3 months, now I have an answer.
~~~~~~~~~~~~~~~~

Unless these posts have recent comments, they stay all the way down on the timeline.
A poster may also have the ability to "pin" the comment to the top of timeline, but not always.

 8)
Title: Re: Sak Recall
Post by: Speedy1wrc on May 26, 2014, 08:38:00 PM
Cartridge 170-C will have no effect on the aluminum. That is what I have been using all along and my aluminum is currently sitting at 20.

I am going to talk to my Dr about going in center using the F180. The sooner I can get my aluminum down the better.
Title: Re: Sak Recall
Post by: caregivertech1 on May 27, 2014, 04:54:45 AM
So here's the question Speedy. Does the 170-C remove the aluminum and your contaminated sacs are putting more back in at the same time ? Don't believe lot numbers on the recall list are aluminum free. What a mess.
Title: Re: Sak Recall
Post by: Speedy1wrc on May 27, 2014, 05:47:31 AM
That's a good question, it is entirely possible. I tried to look up cartridge characteristics last night and came up empty handed. I truly believe there were many more affected !of numbers than were disclosed. My aluminum and other patients was high before the recalled lots.
Title: Re: Sak Recall
Post by: obsidianom on May 27, 2014, 08:11:01 AM
I want to remind everyone this is just the tip of the iceberg. Or in other words dont miss the forest for the trees.
This aluminum problem appears to be part of a much wider problem . In a way it is a syymptom rather than the only issue.
We have here an industry that we cant trust and are at the mercy of. Do any on you trust any of the dialysis products you use now? I dont.
We have Nxstage and Rockwell and perhaps others that we have to question now.
Rockwell may have produced the tainted dialysate for nxstage. It certainly appears from their announcements  they did.  Rockewell also produces much of the in center dialysate concentrates (acid and bicarbonate) for Fresenius and DAvita.  They had at least one substandard manaufacturing plant in SC that had multiple serious violations that could have tainted their product. Every dialysis patient in the country could at some point be effected.
Now we have Rockwell trying to get their new drug for anemia aproved to replace or reduce EPO that will go dirctly into the dialysate in center.  They have been accused of falsifying their test results and lying to the SEC and FDA.
This is a deep tangled web . And I am sure we only have a small part of the story.
So dont just focus on aluminum. That may turn out to be the least important part of the story. It may be a LOT worse than that.
Title: Re: Sak Recall
Post by: Maggie and Jeff on May 27, 2014, 08:01:50 PM
I want to remind everyone this is just the tip of the iceberg. Or in other words dont miss the forest for the trees.
This aluminum problem appears to be part of a much wider problem . In a way it is a syymptom rather than the only issue.
We have here an industry that we cant trust and are at the mercy of. Do any on you trust any of the dialysis products you use now? I dont.
We have Nxstage and Rockwell and perhaps others that we have to question now.
Rockwell may have produced the tainted dialysate for nxstage. It certainly appears from their announcements  they did.  Rockewell also produces much of the in center dialysate concentrates (acid and bicarbonate) for Fresenius and DAvita.  They had at least one substandard manaufacturing plant in SC that had multiple serious violations that could have tainted their product. Every dialysis patient in the country could at some point be effected.
Now we have Rockwell trying to get their new drug for anemia aproved to replace or reduce EPO that will go dirctly into the dialysate in center.  They have been accused of falsifying their test results and lying to the SEC and FDA.
This is a deep tangled web . And I am sure we only have a small part of the story.
So dont just focus on aluminum. That may turn out to be the least important part of the story. It may be a LOT worse than that.

Well said.

We are having an AAMI run on both the sak and the hanging bags so we can pick the least contaminated mix.
Title: Re: Sak Recall
Post by: caregivertech1 on May 28, 2014, 04:53:10 AM
Please post the results when available. Tks.
Title: Re: Sak Recall
Post by: Maggie and Jeff on May 28, 2014, 10:19:12 AM
Please post the results when available. Tks.

Will do.
Title: Re: Sak Recall
Post by: Dannyboy on May 28, 2014, 01:25:05 PM
How frequently are we supposed to be checked for serum Aluminium?   looks like some are tested every few months, others every 6 or 12 months...... Is it more a policy-type thing, rather than a "required" by somebody test?
For me,I can't find that I've EVER been tested for serum Aluminum, both In Center and home with NxStage.   Gonna request the info from the Neph next visit.
PS: oh yeah, I used a bunch of the recalled SAKs.
--Dan
Title: Re: Sak Recall
Post by: obsidianom on May 28, 2014, 01:41:50 PM
I am asking for monthly aluminum for the next few months until I am satisfied this is all cleared up . I dont trust anyone right now . Better to test and be aware then have it sneak up on you.
Title: Re: Sak Recall
Post by: Simon Dog on May 28, 2014, 02:07:15 PM
My clinic tests annually in January.    I was just tested because of the SAK issue (came in at 13) an dam scheduled for a retest in 3 months.
Title: Re: Sak Recall
Post by: Speedy1wrc on May 29, 2014, 06:56:45 AM
Is this post being moderated?

Yesterday I posted about my conversation with NxStage and now it's gone.
Title: Re: Sak Recall
Post by: Maggie and Jeff on May 29, 2014, 07:24:01 AM
I never saw it speedy maybe you should try again.
Title: Re: Sak Recall
Post by: Speedy1wrc on May 29, 2014, 08:37:40 AM
Holy cow. I spent over an hour yesterday writing it. I posted it and checked and it was there. I was wondering why I didn't get any email notifications about any replies. I don't have time today to re-do it.

My conversation with NxStage was an eye opener. I will say this, if you haven't already push your center to relay your concerns, lab results and symptoms to NxStage. As some have wondered, nothing is going on right now on their end.I will provide details when I have time to compose another post darn it.
Title: Re: Sak Recall
Post by: Hemodoc on May 29, 2014, 10:12:38 AM
Actually, I just got called by my dialysis use today. She had  NxStage survey with several questions SHE had to complete. The questions were on MY diet, antiperspirant use, and binder usage. What does that tell you about NxStage and who is going to claim responsibility for these issues? I am going to get a copy of the survey later today.
Title: Re: Sak Recall
Post by: Speedy1wrc on May 29, 2014, 06:56:51 PM
I'm a bit surprised that came from NxStage. From my conversation with them, they have no plan in place to address patient concerns or symptoms. Their plan is to leave it up to centers to attend to any problems. When I spoke to my center (Davita) for their part, their only course of action is to monitor aluminum on a monthly basis.

So hopefully this post doesn't get erased.

I spoke with the Senior VP of Customer Experience at NxStage and boy was it an eye opener. I started by asking why it took a year for them to notice this problem. He said that they in fact do test every batch. He said they did know about the problem with the sodium lactate but didn't see any significant upstream contamination (quote). I pushed him to give a reason why knowing there was a problem that they still shipped the product. He said that they don't hear that there were any problems from the centers. I told him that we reported a problem (me) as far back as April and he acknowledged that there were a few isolated reports of elevated aluminum levels but that they were relying on the centers to determine the causes. I then told him we went through all the proper steps and determined it had to be the SAK's but they declined to admit it was their problem. He vowed he would go back and review what transpired at that point. It was clear that they have moved on and had no plans for any further action.

He asked me what he needed to do and I said they had to regain the trust of the patients as many of us are very angry. He said he would provide me with what they have done to fix this, to which I answered, they needed to publicly address the concerns of all the patients, not just me. He promised me he would be talking to the head of their regulatory group and get back to me. I did get the impression he would follow through on this.

I brought up the issue of patients with multiple symptoms and what they intended to do to help them. Either they really didn't consider that there could be a problem or they are stonewalling. Here he disappointed me. He deferred to the centers to take care of any problems. No matter how I pushed him, he kept deferring to the centers and Dr's. I hit him hard asking about those of us with more serious problems that didn't necessarily have "cures" and he yet again threw it back to the centers. They are deflecting pretty much everything.

In (only) my opinion I feel that they were not expecting nor were prepared to hear there were problems. He claimed that they were relying on feedback from centers to determine if there were problems. He claims they only got reports of a few isolated cases and expected the centers to find the problems elsewhere. If you haven't already, push your center to relay your symptoms and aluminum levels to NxStage.

I probably forgot something. If you have any questions, I'll try to answer them if it's something we talked about. I'll keep you posted on what I hear.
Title: Re: Sak Recall
Post by: Maggie and Jeff on May 29, 2014, 07:37:51 PM
I'm wondering what those AAMIs will show.........and now you have me wondering what NxStage will say about the results especially if they are not good results. :shy;

 :pray; :pray; :pray; I am praying that it's not bad  :pray; :pray; :pray; 

I'll share the info  :grouphug; if the results are good  :beer1;  :2thumbsup; :yahoo;   

But if things are bad  :boxing; :Kit n Stik;  :boxing; we'll need to do what we can  :usaflag; :usaflag; work together and get our message out  :sos; :sos;
Title: Re: Sak Recall
Post by: KarenInWA on May 29, 2014, 07:56:06 PM
There is a thread on the NxStageUsers Facebook page. I'll put the post and comments here but will leave out the names. Wondering what you all think of what is being said here...

Original Post: Has everyone gotten their aluminum test results? Mine is high and we'll be taking them several more times. Since this incident, I've had shortness of breath and the distance I can comfortability walk has decreased. Now Doc is sending me to heart Dr. Not bad to get things checked out, but was wondering if anyone else was having issues. Of course they told me there were no reported complications from the aluminum ...

Comments:

 - We were told that Aluminum Toxicity would be anything over 40-60. How high is yours?

 - Just under toxicity level .... according to them

 - We are getting my husband's test done this week.

 - Mine are elevated

 - <Glad I use only bags at this point> Sorry for those of you exposed to this aluminum issue with the Pureflow saks.

 - Paul's Alluminum was good, but we are now on 405 SAKS for the last little while so I guess that was a good thing

 - Glad we are doing bags instead of pureflow as well.Hope everybody comes out ok with these issues.

 - I called about hubby's results today but was told they had to send them away somewhere!?

 - Make sure they tell you your aluminum levels!

 - Ron's came back as 46 -- pretty upsetting..

 -  I got mine today. It's 20. I was told normal is between 0 and 10. When they told of the recall, I didn't have any of the SAKs but I must have in the past year.

 - That's probably it <above poster>, we wouldn't have known we had any but two boxes (from two separate recalled lots that were shipped to us) didn't get rotated with the others & weren't used yet...that means we used a bunch a couple months ago! Still waiting for aluminum results!

 - Wow <person who stated Ron's levels>, with it being that high, what is the protocol?

 - Mine is 31. They told me they consider toxcity at 40 to 60 for dialysis patients. Linda they should give him the chelate at 46.

 -  I went online to look since nobody else had an answer and sure enough it was there! His is 23 but I'm sure it was probably higher when we were actually using the SAKs 2 months ago.

 - Thanks for the info - I wasn't with him when he got this info, He is going in next week for another blood draw. Someone there told him that number wasn't very high - in fact they said that 200 wasn't to high . I'll have to do more checking.

KarenInWA
Title: Re: Sak Recall
Post by: slipkid on May 29, 2014, 09:23:35 PM
Here is a 2 page letter from Davita's chief medical officer regarding the aluminum contamination issue.  Note the date of the letter and the paragraph on the second page which states that 10 micrograms per liter is the "lower limit of precision" of their test.  My blood test report notes an acceptable range of 0-10 micrograms per liter.

The question mark on the second page was added by my neph.
Title: Re: Sak Recall
Post by: obsidianom on May 30, 2014, 02:50:44 AM
our nephrologist is concerned with any number over 20 . She feels this is the cutoff for any potential danger. She is older and remembers the issues with aluminum back in the early 1980s.  WE had ours drawn yesterday . WE will see.

In addition our nephrologist gave me a copy of the latest "Up to Date "  printout on aluminum toxicity and treatment. One thing stood out.   "EXCESS ALUMINUM DEPOSITION IS UNLIKELY IN PATIENTS WITH BASELINE SERUM ALUMINUM CONCENTRATIONS UNDER 20 MC/L."   
In other words over 20 is BAD and aluminum begins to deposit in bone and organs.  A word to all . Watch out if your number is over 20.

I disagree with Davita on this based on what my nephro and the 2013 guide I just read . Davita claims over 40 as the cutoff. They quoted a 2005 paper. My up to date guide claims 20 is the magic number. So beleive what you want but I dont trust Davita as they would probably have to deal with more fallout if they dropped the number . My number comes from non financially involved sources.
Title: Re: Sak Recall
Post by: amanda100wilson on May 30, 2014, 08:38:18 AM
I am not sure what you expect NxStage to do if someone has problems.  Of course it is up to the units to sort out any problems that have occurred.  What are NxStage supposed to do?  I am sure that there is Likely to be a class action lawsuit and NxStage's responsibility will be to pay out monetary compensation.  I am pretty sure that their legal team have already primed them what yo say to patients.  Not sure how easy it will be to prove that harm has been done unless as Peter says, people have invasive procedures such as bone biopsies.
Title: Re: Sak Recall
Post by: Dannyboy on May 30, 2014, 10:49:52 AM
Thanks slipkid for posting the Davita letter.   Interesting.

My Aluminum came in at 27 this month.    Wish there was more of a medical consensus on what level is a serious problem.   My Davita unit doesn't regularly check for Aluminum it turns out.....mine was previously checked in 2011 (!)...[it was 6 at that time].   Not sure if it is their policy or if they were/are just being lazy/overlooking/too busy to  be testing for aluminum more frequently.

Received replacement SAKS from NxStage yesterday via UPS (to replace recalled boxes). 



Title: Re: Sak Recall
Post by: Speedy1wrc on May 30, 2014, 11:35:56 AM
While it seems we have become strictly statistics, let's not rest comfortably as such.

My levels have been in the 20 range and I am definitely suffering symptoms. I am not following the trend I guess.

From reading an article in the Telegraph a woman died of complication of dementia. Her serum aluminum was 28. The complete autopsy report is forthcoming. Post mortem brain tissue results show aluminum in the 20-30 range for many subjects diagnosed with Alzheimer's.

You can find many data sets and depending on which side of the problem you are on can determine which sets you use.

The second letter above states no symptoms have been reports and in a sense I may agree with that. Unless a nurse/patient team is actively pursuing a cause for a symptom it could easily just be brushed aside. For example I was dealing with dry skin all Winter. It was easy to write it off as dry air. But it still continues and only now going back seeing when it started does it start to make sense. The metallic taste was reported to my team, but lacking any sense that it was/caused by a systemic prblom it just gets filed away. Now is the time to start looking at symptoms over the last year to determine if there is any correlation.

As for what NxStage should, they should pro actively be involved with determining if anyone was harmed. From what I garnered from my conversation was, hear no evi,l see no evil.

I did forget something from my conversation. He did say that they would continue to work with their providers to ensure product compliance.
Title: Re: Sak Recall
Post by: Hemodoc on May 30, 2014, 01:09:43 PM
I am not sure what you expect NxStage to do if someone has problems.  Of course it is up to the units to sort out any problems that have occurred.  What are NxStage supposed to do?  I am sure that there is Likely to be a class action lawsuit and NxStage's responsibility will be to pay out monetary compensation.  I am pretty sure that their legal team have already primed them what yo say to patients.  Not sure how easy it will be to prove that harm has been done unless as Peter says, people have invasive procedures such as bone biopsies.

Well, NxStage has many duties and obligations in their fiduciary responsibilities to all of their patients.

1) Complete disclosure on exactly WHAT happened and WHY.

2)  Monitoring of all patients potentially affected for any adverse future events with compensation for any that occur.

3) Compensation for anyone harmed by their product right now.

4) Improvement of the quality control systems so that this or other problems do not occur.

These are just some that come to mind off the top of my head, but NxStage has much yet to do.
Title: Re: Sak Recall
Post by: Simon Dog on May 30, 2014, 01:14:52 PM
3) Compensation for anyone harmed by their product right now.

"Compensation" is tricky, given the difficulty of proving an elevated AL level is responsible for problems.    Mine went from 5 to 13 while on the bad SAKs.  Should I be compensated due to the worry and anxiety even though, at present, I have no symptoms from the NxStage product other than continued life?   I'm sure some contingency fee lawyer will have ads on late night TV offering to sort this out for us.
Title: Re: Sak Recall
Post by: Hemodoc on May 30, 2014, 01:38:27 PM
3) Compensation for anyone harmed by their product right now.

"Compensation" is tricky, given the difficulty of proving an elevated AL level is responsible for problems.    Mine went from 5 to 13 while on the bad SAKs.  Should I be compensated due to the worry and anxiety even though, at present, I have no symptoms from the NxStage product other than continued life?   I'm sure some contingency fee lawyer will have ads on late night TV offering to sort this out for us.

In your case, proving harm would likely not result in a successful case. However, there are many with levels over 30 and 40. If harm has occurred, then yes, NxStage SHOULD compensate them.

Individual lawsuits are notoriously difficult to prove with 90% going in favor of the practictioner.  Class action lawsuits are a different story.
Title: Re: Sak Recall
Post by: Simon Dog on May 30, 2014, 04:49:05 PM
Individual lawsuits are notoriously difficult to prove with 90% going in favor of the practictioner.  Class action lawsuits are a different story.
Yup - It's an entirely different ballgame that auto accidents where the insurance companies will settle even in the fact of a police report showing the defendant driver was not at fault.
Title: Re: Sak Recall
Post by: obsidianom on May 31, 2014, 05:13:16 AM
I hate lawsuits and lawyers. WE didnt even sue when the surgeon screwed up my wifes stomach and left her on a feeding tube for life. Maybe we should have as it was a clear cut horrible result but we chose to accept "shit happens" and move on without the stress of a lawsuit.
A certain doctor in another country who was informed about the aluminum issue has in no uncertain terms told me we should move on , accept the mistake , and stop making so much out of it. That doctor just doesnt like the American mentality of suing for every mistake.
Now I am not saying I am not royally ticked off by this . I AM.    But my first and formost goal is getting the company to make sure it NEVER happens again or any other mistake like this . I want to stay with Nxstage and still beleive in their system . I want them to improve their quality control and be more careful in the future.
I still beleive there is a bigger problem out there as I have posted numerous times about . It involves another company and their new drug for dialysis patients, questionable facilities and coorporate mindset . They have a lot more effect on all dialysis patients then Nxstage. They could be involved in the Fresenius recall of contaminated dialysate solution. I dont know if they are but I have my suspicians. We will see.
Title: Re: Sak Recall
Post by: Speedy1wrc on June 06, 2014, 07:39:11 PM
Anyone get recent aluminum values yet? I had mine checked two weeks ago then day after the recall. I just had it checked again Wednesday. I was expecting the results today, but they weren't back yet. I hope to have them Monday.
Title: Re: Sak Recall
Post by: Maggie and Jeff on June 06, 2014, 08:06:23 PM
Dialysate AAMI came back >.005 aluminum in both the Sak (lot 40379185) and the hanging bags.  All other #'s were in range.
Title: Re: Sak Recall
Post by: Angiepkd on June 06, 2014, 08:09:55 PM
I spoke with my transplant doc today about the high aluminum levels I had while using NxStage.  I asked if I should have my aluminum levels checked now, post tx.  He did not think so, as my new kidney would be filtering any aluminum.  If I push the issue, I am sure I can get him to order the test, but was wondering what you all thought?  He had not heard of the recall or the aluminum problems, but he deals only with transplant patients, so I can maybe understand that.  However, he does work in the same office with several other docs who deal with dialysis patients, including my primary neph who tried to help me figure out the source of my aluminum.  Wouldn't there be some type of communication there?  There are several NxStage pamphlets in the waiting room, but nothing about a recall.  I am curious if my dialysis clinic has anything posted about it.  I may call my D nurse Monday and ask her if her patients were notified.
Title: Re: Sak Recall
Post by: Speedy1wrc on June 06, 2014, 08:15:25 PM
Every patient on NxStage should have received a packet from their center and also one directly from NxStage.
Title: Re: Sak Recall
Post by: caregivertech1 on June 07, 2014, 04:44:11 AM
Anyone get recent aluminum values yet? I had mine checked two weeks ago then day after the recall. I just had it checked again Wednesday. I was expecting the results today, but they weren't back yet. I hope to have them Monday.

As of June 2nd my wife's level was still 20. Neph says it's probably in the tissue and will take time to gradually remove it. Just recently went to 30L(from 25) which extended out time on the cycler to over 3 hrs. which should help.
Title: Re: Sak Recall
Post by: obsidianom on June 07, 2014, 05:53:13 AM
My wifes aluminum is at 44.  She is small so it accumulated a lot. I am not happy about it.  We are deciding what to do about it now. Our nephrologists are not happy either. WE certainly will moniter it closely now.
Title: Re: Sak Recall
Post by: Angiepkd on June 08, 2014, 07:02:20 PM
My wifes aluminum is at 44.  She is small so it accumulated a lot. I am not happy about it.  We are deciding what to do about it now. Our nephrologists are not happy either. WE certainly will moniter it closely now.

I am so sorry your wife's levels are still so high.  I am still unclear about the accumulated aluminum.  Will it be filtered out by dialysing with uncontaminated SAK's?  How much aluminum stays in the tissue?  Sorry if this is a stupid question, but I am not finding any clear answers in my research.  Maybe I have missed something. 
Title: Re: Sak Recall
Post by: Hemodoc on June 08, 2014, 07:36:15 PM
My wifes aluminum is at 44.  She is small so it accumulated a lot. I am not happy about it.  We are deciding what to do about it now. Our nephrologists are not happy either. WE certainly will moniter it closely now.

I am so sorry your wife's levels are still so high.  I am still unclear about the accumulated aluminum.  Will it be filtered out by dialysing with uncontaminated SAK's?  How much aluminum stays in the tissue?  Sorry if this is a stupid question, but I am not finding any clear answers in my research.  Maybe I have missed something.

Yes, it is treatable with Desferoxamine chelation. Here is an article showing reversal of microcytic (small cell) anemia with that treatment.

http://www.ajkd.org/article/S0272-6386(87)80058-6/pdf
Title: Re: Sak Recall
Post by: Angiepkd on June 08, 2014, 07:39:39 PM
Thanks, Hemodoc!
Title: Re: Sak Recall
Post by: Speedy1wrc on June 09, 2014, 11:53:01 AM
I just texted my nurse and found my aluminum is down to 17. Better than before but still high. My HgB jumped up a tad too.

I have free time on Friday and I think I am going to stretch my treatment out to see if I can "clean" myself out better.
Title: Re: Sak Recall
Post by: obsidianom on June 09, 2014, 01:21:57 PM
What are you doing to lower it?
Title: Re: Sak Recall
Post by: Speedy1wrc on June 09, 2014, 06:30:09 PM
Actually nothing. I am assuming the dialzer is removing some. I have no residual kidney function, so they're not helping. I'm not sure I am otherwise excreting any aluminum?
Title: Re: Sak Recall
Post by: Hemodoc on June 09, 2014, 07:06:15 PM
Serum levels of aluminum are notoriously inaccurate. Tissue samples usually from the bone secure the diagnosis. I don't believe I will volunteer for that test.  A surrogate marker is microcytic anemia (small cell). If the serum levels are improving and the anemia is improving, the serum levels may in fact be telling. But once again, serum levels do not reflect the aluminum in the tissues.
Title: Re: Sak Recall
Post by: Maggie and Jeff on June 09, 2014, 07:34:54 PM
Can the aluminum be removed via sweeting?
Title: Re: Sak Recall
Post by: Hemodoc on June 09, 2014, 10:05:48 PM
Can the aluminum be removed via sweeting?

Yes, but not as efficiently as healthy kidneys, but sweat, urine, liver and feces are the routes of elimination of aluminum. However, excessive sweating in some dialysis patients may not be healthy.
Title: Re: Sak Recall
Post by: Hemodoc on June 12, 2014, 06:13:02 PM
Here is the article from the Boston Globe. There are several folks here on IHD that were contacted by the Boston Globe reporter. The article covers some of the basics, but I would have liked to have seen a better investigative report. In the end, we haven't learned anything new from the article.

http://www.bostonglobe.com/business/2014/06/11/recall-fluid-used-home-dialysis-shocks-worries-patients/kUHgQHt90pw7OHx95PebSJ/story.html
Title: Re: Sak Recall
Post by: Speedy1wrc on June 12, 2014, 07:58:56 PM
If NxStage wanted to keep it on the DL that idea is toast.

I'm just glad the word is out.

It was pretty soft however.
Title: Re: Sak Recall
Post by: caregivertech1 on June 13, 2014, 08:25:09 AM
So many unanswered questions for NxStage. Glad the article was written and thanks to those who participared. Still can't believe no lawsuites.
Title: Re: Sak Recall
Post by: Hemodoc on June 13, 2014, 11:36:52 AM
So many unanswered questions for NxStage. Glad the article was written and thanks to those who participared. Still can't believe no lawsuites.

Lawsuits literally take years. That does not mean there won't be any in the near future. There is usually a 5-7 year statute of limitations. It takes time to find all the information a lawyer needs under discovery. That is just one more flawed aspect of her article.  Even the title is dismissive in itself. Good grief, patients are "upset." Patients get upset when they have to wait 10 minutes. I would state that this goes beyond upset by a wide, wide margin. To say the least, can we trust this company any longer.  Did they put profits ahead of patient safety? What caused a company with an excellent safety record to go to a company where the patients have serious doubts about continuing with this company? Where was the sentiment reflected in her article. And then to end with a financial analyst that states we have no choice. Good grief. Terrible reporting.
Title: Re: Sak Recall
Post by: Dannyboy on June 14, 2014, 10:24:53 AM
Yes, the article left many questions unanswered.  I hope it is the start of more details forthcoming.
One point in the article that was news to me is that "140,000 to 150,000 units" were recalled.  That is a lot of SAKs. 
Hopefully NxStage will disclose the total number of treatments made with recalled SAKs, but I guess that would have to wait for legal discovery from what I'm hearing above.
Also discussed here:
http://ihatedialysis.com/forum/index.php?topic=31234.0 (http://ihatedialysis.com/forum/index.php?topic=31234.0)
Title: Re: Sak Recall
Post by: caregivertech1 on June 23, 2014, 09:37:16 AM
Just FYI, after being in the 20's for a year our aluminum is now 13 after using the "uncontaminated" sacs. Still surprised they allow 10 micrograms in their processing as an upper limit. Wonder if that has been changed. I certainly hope so.
Title: Re: Sak Recall
Post by: Hemodoc on June 23, 2014, 09:59:01 AM
Just FYI, after being in the 20's for a year our aluminum is now 13 after using the "uncontaminated" sacs. Still surprised they allow 10 micrograms in their processing as an upper limit. Wonder if that has been changed. I certainly hope so.

No, NxStage will not come anywhere near that in the future. Lessoned learned so to speak from top ranking corporate officials at NxStage that I spoke with about a week ago. I will finish up a post for my blog soon after I have had a chance to get feedback from a few different companies with associations to NxStage. I suspect all will either not respond or choose no comment. NxStage will not comment until the FDA report and investigation is completed due to regulatory constraint. But they do want to tell the story when they can.

But yes, the K/DOQI guidelines of 10 microgram/liter definitely are way too high.
Title: Re: Sak Recall
Post by: Hemodoc on June 23, 2014, 09:57:06 PM
Here is my first post on Hemodoc for over a year on the NxStage aluminum issue. I hope this answers SOME of the questions surrounding this event. The final story will not be written without disclosure from NxStage after the FDA report is finalized. I cannot claim credit for this story since I came upon this information from an anonymous source who wishes to remain that way. I don't use confidential information in any of my posts since I have no legal department as a safety net so this is as far as I can take this story at this time. I look forward to the completion of the FDA report. This continues to be a significant event in many ways that needs full disclosure to prevent any similar or like occurance in the future.

http://www.hemodoc.info/2014/06/nxstage-aluminum-contamination-is-rockwell-medical-at-fault-1.html

Please note that my URL has changed to www.hemodoc.info. All prior posts can be accessed with the new URL.
Title: Re: Sak Recall
Post by: obsidianom on June 24, 2014, 08:14:34 AM
I want to be the first to write, EXCELLANT BLOG/ARTICLE . You gave us what the newspaper article missed. At least we have a target now to look at in terms of whom is to blame. Its too bad the news paper didnt take the oportunity to go into the same depth, it may have helped a lot.
So thank you Hemodoc/Peter for getting your blog going again and writing about this issue we all dealt with .
In the end my only goal and concern is that this never happen again, no matter who is to blame. My wife still has very high aluminum levels. It was 44 last month. In 2 days we will see the latest. So we were effected a lot.
I still beleive in Nxstage and will continue to use it and support the company. I dont however trust Rockwell. I wont let my wife use their new drug, Triferic.
Title: Re: Sak Recall
Post by: caregivertech1 on June 24, 2014, 02:19:00 PM
Ditto...Thank you Hemodoc.
Title: Re: Sak Recall
Post by: PrimeTimer on June 24, 2014, 07:57:26 PM
Thank you, Hemodoc for including the link to your article. This whole thing (SAK recall) has been upsetting and their quality control has lost some credibility. We will continue using NxStage products but this is very angering, very disappointing and downright scary.
Title: Re: Sak Recall
Post by: Hemodoc on June 24, 2014, 09:36:26 PM
Thank you, Hemodoc for including the link to your article. This whole thing (SAK recall) has been upsetting and their quality control has lost some credibility. We will continue using NxStage products but this is very angering, very disappointing and downright scary.

Thank you again, but as noted above, this is not really my story.  There is more to the story, but from public records, this is all I could confirm.

As far as quality control, I will be writing a follow up article on the quality control issue. That will add a bit more to the picture, but until we have the FDA records, i don't believe we will be able to confirm all the details of this event from what is in the public record.

I did talk to the VP in charge of quality control and I do believe NxStage will make the necessary corrections in quality control especially when they outsource to other companies.  We will wait and see, but the folks I spoke with at NxStage, while not divulging details unknown to the public, did assure me that the FDA has a good working relationship with NxStage and they felt confident that the process will meet all "specs" and that their product will continue on the path it had previous to this event. I take them at their word at this point in time.
Title: Re: Sak Recall
Post by: Dannyboy on June 25, 2014, 07:00:17 AM
Thanks for the link/blog posting.  Can't wait for "the rest of the story".
Title: Re: Sak Recall
Post by: Speedy1wrc on June 26, 2014, 08:51:34 PM
More of "the ret of the story".

I spoke with an official at NxStage as well. While we have assumed that these lot's slipped through the cracks, they didn't. We wondered how they could either not be testing or have missed that the aluminum level was high. Well get ready to be really angry because they did know the aluminum was high. And they knew it a year ago.

I was told that they, " didn't forsee any issues with upstream contamination". Yup, they knew about the problem and made an active decision to ignore it. Are you seething yet? I asked how could they do that, and the answer was that since they didn't have any reports of elevated aluminum levels or any reports of symptoms, they decided it wasn't a problem. Now you're spitting nails right? I told him that I know that was false since we reported several patients using SAK's as opposed to bag's who had dramatic and sudden elevation of aluminum levels. I will quote my nurse, she said "I was freaking out at them about this". I was promised that he would go back and find out what happened back then and get back to me. I am still waiting.

We all are wondering what NxStage is doing about this. In terms of the affected patients. Don't hold you breath, because they are doing NOTHING. Over and over I asked this and the answer I got every time was, "talk to your center". I said that they weren't the ones responsible for making us sick and the stonewalling kept going. Over and over, "talk to your center". I specifically asked what about long term problems, those which we can't predict at this point, and the answer was still the same.

the conversation was over the phone and while not in person, I do honestly believe he was stunned that there were patients who are sick. I think they stuck their head in the sand with this and I think I triggered a run down the hall to say, hey fella's we have a problem. He promised me that he would tell ME what has been done from a product standpoint to fix this. I told him back that they needed to tell everyone, not just me. That caught him off guard I felt. He said he would look into it and get back to me. I stopped holding my breath awhile back. I haven't heard from him since. I have a fw hours to kill tomorrow morning and I shall give him a call back to let him know I am not dropping this.

I made it clear that there were a lot of very upset patients and many who were showing distinct symptoms. I didn't get any apology, but he was served notice that they indeed have a problem they will need to deal with. I also let him know that this wasn't a whisper quiet discussion but that it was exploding over social media and they really needed to deal with it. Once again I was promised action. Yeah right.

I too am very upset. I have many symptoms and to put it bluntly, they made me sick.
Title: Re: Sak Recall
Post by: Hemodoc on June 26, 2014, 10:07:40 PM
Wow, if confirmed that changes things significantly. That is not good news. Thanks for the update. I didn't get any of that sort of information from the folks. I did ask them how they missed it and why it wasn't picked up in post production testing. Wow. That is not good. If that is in the FDA report, NxStage will take a big hit. Not good.  I was planning on doing a follow up post on the NxStage quality control failure. Looks like I have a lot more homework to do. Wow. If they knew and didn't take corrective action, that really opens them up to liability. Wow. That is perhaps the worst information about this whole mess I have heard yet.
Title: Re: Sak Recall
Post by: iolaire on June 27, 2014, 05:48:40 AM
I spoke with an official at NxStage as well.
I'm very surprised that they would even talk to you.  Being a corporation I'm sure that they have had some guidance from their legal department on what to say - nothing - and who to say it to - no one.  Even if an executive wanted to do say something publically I'm quite sure that their legal team would block it as much as possible.  They are in a protected situation where the centers are their clients, and they can defer all patient communication to the centers.  The legal team would re-enforce that relationship as much as possible because it prevents employees from talking to patients.
Title: Re: Sak Recall
Post by: Dannyboy on June 27, 2014, 08:25:09 AM
Wow.  Speedy, no doubt you made notes on WHO you talked to, etc.


If the statements made to Speedy are owned up to by NxStage publicly, I can hear the NxStage "spin" coming here.....  "Yeah we knew the SAKs were 'beyond spec' but the issue didn't rise to the level serious enough to dump 140,000 already manufactured units...and also 'we had no reports of problems from the field' [FALSE as posters on IHD have stated]...' "


I can hear echoes of the Late Senator Howard Baker (during the Watergate Hearings)....[as if to NxStage]: "What did you know, and when did you know it?"


This thing is getting smellier by the day...and yeah, pisses me off big time as I too, have adverse symptoms.


Title: Re: Sak Recall
Post by: Speedy1wrc on June 27, 2014, 08:48:57 AM
I don't know what will happen next. On the NxStage Users group on FB it has grown legs. Patients are now coming out and speaking up. Hopefully that will elicit some sort of reaction from NxStage.
Title: Re: Sak Recall
Post by: Simon Dog on June 27, 2014, 02:15:49 PM
"Yeah we knew the SAKs were 'beyond spec' but the issue didn't rise to the level serious enough to dump 140,000 already manufactured units...and also 'we had no reports of problems from the field' [FALSE as posters on IHD have stated]...' "
If the NxStage contract negotiation team was on the ball, the supplier to NxStage, and not NxStage, would bear the financial risk of any product delivered to NxStage out of spec.   
Title: Re: Sak Recall
Post by: Hemodoc on June 27, 2014, 03:15:55 PM
"Yeah we knew the SAKs were 'beyond spec' but the issue didn't rise to the level serious enough to dump 140,000 already manufactured units...and also 'we had no reports of problems from the field' [FALSE as posters on IHD have stated]...' "
If the NxStage contract negotiation team was on the ball, the supplier to NxStage, and not NxStage, would bear the financial risk of any product delivered to NxStage out of spec.

Being in "spec" is not enough. K/DOQI says 10 mcg/liter is fine. Well, it isn't. I spoke to Joe Turk and he used that term, all products today are "in spec." I didn't consider it at that time, but that is not actually reassuring to me. Purac produces products at 0.11 mcg/liter. 10 mcg/liter is a hundred times greater than the best lactate producer in the world. I hope and pray that NxStage is using the best producer of lactate. If not, I am DONE with them. Maybe not tomorrow, but done when I have an option I consider viable.
Title: Re: Sak Recall
Post by: Speedy1wrc on June 27, 2014, 05:37:08 PM
"Yeah we knew the SAKs were 'beyond spec' but the issue didn't rise to the level serious enough to dump 140,000 already manufactured units...and also 'we had no reports of problems from the field' [FALSE as posters on IHD have stated]...' "
If the NxStage contract negotiation team was on the ball, the supplier to NxStage, and not NxStage, would bear the financial risk of any product delivered to NxStage out of spec.
The only problem with that is that NxStage knew it was "out of spec" and they decided to still use it. That is their problem right now.
Title: Re: Sak Recall
Post by: Hemodoc on June 27, 2014, 09:40:42 PM
"Yeah we knew the SAKs were 'beyond spec' but the issue didn't rise to the level serious enough to dump 140,000 already manufactured units...and also 'we had no reports of problems from the field' [FALSE as posters on IHD have stated]...' "
If the NxStage contract negotiation team was on the ball, the supplier to NxStage, and not NxStage, would bear the financial risk of any product delivered to NxStage out of spec.
The only problem with that is that NxStage knew it was "out of spec" and they decided to still use it. That is their problem right now.

True and not good.
Title: Re: Sak Recall
Post by: caregivertech1 on June 29, 2014, 05:22:56 AM
Also Nxstage knew most centers only test for aluminum once or twice a year (or not at all). Our Al was tested at 25 the first week of June 2013 using saks not even on the recall list. If I'm Nxstage all I'd have to do is check with their own Spectra Labs and ask "Hey, any high aluminum numbers out there?". I'll bet they did and the coverup was on.
Title: Re: Sak Recall
Post by: amanda100wilson on June 29, 2014, 10:43:57 AM
I am pretty sure that NxStage could not get data from Spectra, since this would be breach of confidentiality laws.
Title: Re: Sak Recall
Post by: Hemodoc on June 29, 2014, 12:33:16 PM
Also Nxstage knew most centers only test for aluminum once or twice a year (or not at all). Our Al was tested at 25 the first week of June 2013 using saks not even on the recall list. If I'm Nxstage all I'd have to do is check with their own Spectra Labs and ask "Hey, any high aluminum numbers out there?". I'll bet they did and the coverup was on.

If some of the recent allegations made show that NxStage KNEW that the aluminum levels were elevated and continued use of the product, then that is going to be an fatal offense in my opinion. What I am now worried about is that I have heard that the current SAKs are "within specs." Does that mean that we now have levels less than 10 mcg/liter but still greatly elevated beyond Purac's -0.11 mcg/Liter that they produce? If so I am done with this company.
Title: Re: Sak Recall
Post by: Speedy1wrc on June 30, 2014, 10:53:00 PM
When I spoke to NxStage I jumped all over their assertion that they knew about the problem a year ago. That didn't fly with me. I don't think they expected the anger. I came right out and asked how they could know about this and continue to poison us. I think at that point is when the wall went up and I stopped getting answers.

DaVita does aluminum quarterly after a baseline at the start.

Caregiver Amanda and I also reported high aluminum back before the supposed recalls. I think we all suspect its been going on longer than admitted.

We may find out soon if the SAK's are any "better". Hopefully they are. We are investigating that now.
Title: Re: Sak Recall
Post by: Dannyboy on July 07, 2014, 09:31:46 AM
The NxStage Sak recall has (finally) appeared on the weekly "FDA Enforcement Report"
Here is a link to the Report:
http://www.accessdata.fda.gov/scripts/enforcement/enforce_rpt-Product-Tabs.cfm?action=Expand+Index&source=govdelivery&utm_medium=email&utm_source=govdelivery&w=07022014 (http://www.accessdata.fda.gov/scripts/enforcement/enforce_rpt-Product-Tabs.cfm?action=Expand+Index&source=govdelivery&utm_medium=email&utm_source=govdelivery&w=07022014)

The recall designated by the FDA as a "Class II" event.  Here is the FDA's definition of that: (Red highlight added)
***begin FDA clip***
Classification - Numerical designation (I, II, or III) that is assigned by FDA to a particular product recall that indicates the relative degree of health hazard.***end FDA clip****

The report doesn't provide any "how it happened", mostly a repeat of what we got from NxStage.
Interestingly, it describes the scope of the recalled product as:
 
"Worldwide Distribution - USA (nationwide) and Internationally to France, Netherlands, Spain, Sweden, and the UK."

Perhaps those more knowledgeable about how the FDA does things can chime in as to whether more detailed info from FDA is likely coming??
--Dan
Title: Re: Sak Recall
Post by: Hemodoc on July 07, 2014, 10:21:13 AM
The NxStage Sak recall has (finally) appeared on the weekly "FDA Enforcement Report"
Here is a link to the Report:
http://www.accessdata.fda.gov/scripts/enforcement/enforce_rpt-Product-Tabs.cfm?action=Expand+Index&source=govdelivery&utm_medium=email&utm_source=govdelivery&w=07022014 (http://www.accessdata.fda.gov/scripts/enforcement/enforce_rpt-Product-Tabs.cfm?action=Expand+Index&source=govdelivery&utm_medium=email&utm_source=govdelivery&w=07022014)

The recall designated by the FDA as a "Class II" event.  Here is the FDA's definition of that: (Red highlight added)
***begin FDA clip***
Classification - Numerical designation (I, II, or III) that is assigned by FDA to a particular product recall that indicates the relative degree of health hazard.
  • Class I: Dangerous or defective products that predictably could cause serious health problems or death. Examples include: food found to contain botulinum toxin, food with undeclared allergens, a label mix-up on a lifesaving drug, or a defective artificial heart valve.
  • Class II: Products that might cause a temporary health problem, or pose only a slight threat of a serious nature. Example: a drug that is under-strength but that is not used to treat life-threatening situations.
  • Class III: Products that are unlikely to cause any adverse health reaction, but that violate FDA labeling or manufacturing laws. Examples include: a minor container defect and lack of English labeling in a retail food.
***end FDA clip****

The report doesn't provide any "how it happened", mostly a repeat of what we got from NxStage.
Interestingly, it describes the scope of the recalled product as:
 
"Worldwide Distribution - USA (nationwide) and Internationally to France, Netherlands, Spain, Sweden, and the UK."

Perhaps those more knowledgeable about how the FDA does things can chime in as to whether more detailed info from FDA is likely coming??
--Dan

This is simply a summary of the last 3 months of FDA recalls if I remember correctly from a few days ago. In any case, it is a summary with no new information since the NxStage notifications.

I believe that we do know the underlying mechanism of aluminum contamination in the lactate dialysate. I am unable to go further because NxStage will not confirm at this time the exact mechanism, but I am convinced by circumstantial evidence alone that Rockwell new to the manufacture of lactate products did NOT use Purac. I can state that because Purac recently sent me a reply stating that they are NOT involved in this FDA recall, but Purac would not confirm who there clients are per long standing policy. But interestingly they DID state that they were not involved in this. Purac manufactures lactate products, pharmaceutical grade at 0.1 ppm (.11 mcg/liter) aluminum purity. That compares to the diluted aluminum contamination of 11-13 mcg/liter in the SAK. Note, that prior to diluation, this would be SIGNIFICANTLY higher in the concentrate.

The source of lactate that I heard from which I have heard from anonymous sources is the source of the PiSA bagged dialysate and previously the concentrate is Purac. That is why until Rockwell, we never had any difficulty with aluminum. I am not able to confirm this information publicly from any spokesperson at PiSA, NxStage or Rockwell and Purac won't divulge their clients either. But that is unconfirmed confidential information I cannot use as a source in a story because I don't use confidential information for any of my articles.

So, yes, we do know what happened in reality. Purac was the producer of our lactate for the dialysate and still is for the bags. That is why they are not involved. If I can ever find a source in public records or a company representative that will confirm any of this information, I would be more than happy to write it up. But I don't use single source information ever. But I am convinced by circumstantial evidence that this is the case but I won't go with a story on this as such. One source is not enough to make an accusation so at present I am treating this as a rumor I have heard only. Is it likely true, I don't print rumors on my blog so I can't do anything with that information other than help me know what to look for. I believe it is so, but I can't confirm it yet with a second source, so at this point it is not above the level of a rumor. That is not enough but hearsay which is not acceptable evidence I can use.

Rockwell I believe is the key, but I can't find the smoking gun to nail it directly to them accept by circumstantial evidence alone. Purac did state categorically that they are not involved and I can use that publicly. We know that Rockwell who is contracted to make the SAK concentrate did NOT use Purac. That we know from a publicly proven source by email a few days ago from Purac.

The real question comes down to the quality control at NxStage. Who knew and when did they know? I believe there are some interesting answers to that which I can soon print as well. I believe NxStage KNEW that their product had high aluminum and went and sold that product anyway. That is a TERRIBLE indictment.
Title: Re: Sak Recall
Post by: slipkid on July 08, 2014, 04:06:32 AM
As I understand your theory, the source of the lactate used in the premixed bags and concentrated SAKs, prior to Rockwell’s involvement, was Purac.  Am I to understand that Purac manufactured the lactate with an aluminum level 100 times better than the minimum ANSI/AAMI standard at an undisclosed plant (presumably in the US) and shipped by tanker truck this lactate to Mexico where it was used to make the concentrated SAKs, and the remainder diluted to make the premixed bags? Alternatively, were two shipments, one of the concentrated lactate and one for the premixed bags made by Purac?

Premixed bags, uncontaminated, and contaminated SAKs in my possession all have made in Mexico printed on them, so it appears that PiSA, and possibly another firm, were involved with the manufacture of the premixed bags and SAKs.

However, Purac’s involvement strikes me as a peculiar theory given the fact the PiSA is a pharmaceutical manufacturing company and may be capable of making sodium lactate on its own. This would also seem to confirm why, “Purac recently sent me a reply stating, Purac would not confirm who there(sic) clients are per long standing policy.”  Do you know with certainty from your anonymous source that Purac had any involvement with PiSA within the last year and a half?  If they did not, it would explain why Purac was quite willing to offer that they had no involvement with the recall.

You claim that, “The source of lactate that I heard from (which I have heard from) (sic) anonymous sources is the source of the PiSA bagged dialysate and previously the concentrate is Purac”. Earlier you claim that, “Purac manufactures lactate products, pharmaceutical grade at 0.1 ppm (.11 mcg/liter) aluminum purity. That compares to the diluted aluminum contamination (emphasis added) of 11-13 mcg/liter in the SAK.”  What do you mean that this “compares to the diluted aluminum contamination of 11-13 mcg/liter in the SAK?”  Are you not confusing what is allegedly produced by Purac with Rockwell?

I am also confused that a Nxstage representative stated earlier in this thread that the dialysate is now “within spec.”  What spec is this? The 0 .11 microgram per liter limit (Purac), or the ANSI/AAMI standard of 10 micrograms per liter (likely PiSA)?
 
You chastised me in a different thread for not revealing my source.  I suggest you look to your own use of anonymous sources as to what you have suggested regarding the Purac- PiSA connection. You state, “So, yes, we do know what happened in reality. Purac was the producer of our lactate for the dialysate and still is for the bags. That is why they are not involved. If I can ever find a source in public records or a company representative that will confirm any of this information, I would be more than happy to write it up.” (emphasis added)
Title: Re: Sak Recall
Post by: Hemodoc on July 08, 2014, 08:29:45 AM
An anonymous source outside of NxStage relayed this information. I can't use that as anything more than a rumor at this point on my blog. No, anonymous source no matter how sincere are just that. I do not believe that PiSA is involved in this, BUT, I can't get a direct phone to a pr person and I can't get a question through on NxStage on their contact page. My information PRIOR to Purac stating that they were not involved is that Purac was not involved. It is confirmation of what I was told, but it is not enough as you state to treat my information as anything more than a rumor at this time.  My gut feeling is that it is the correct information.

NxStage has their own plant in Mexico as well from my understanding. I may be wrong on that and don't have the time or the inclination to look up that information again, but that is my understanding.

So, I do believe that in the end, this will be the correct path for what occurred.

If I offended you in a prior post, I apologize. That was not my intent. I just believe that what I was told from a source outside of NxStage is likely credible. I have heard other "rumors" as well. I only mention this rumor since it seemed to pertinent to the ongoing discussion. There are other rumors I have heard that I cannot confirm as well. I only write in my blog that which I can confirm by various sources. I wish we had those sources right now, but after a very diligent search, it remains an unconfirmed rumor and I am posting this and the last post as such.

As far as "in spec." Yes, that is a great worry for me as well. 10 mcg/liter is WAY too high for aluminum in dialysate. That is what I was told by  NxStage administrator and that statement bothers me greatly. Someone was going to have their current SAKs tested for aluminum to see exactly what it is right now. That is information we need to have.

Sorry again if I offended in the other discussion on your anonymous source. It is simply that the information you provided conflicted with what I have heard from unconfirmed sources. Until we are able to hear the direct details from someone in the FDA, Rockwell, Pisa or NxStage, we will remain much in the dark. That is how I am treating the rumors I have heard. I did talk to two folks at NxStage in high administrative positions and I asked them about all of these issues but neither would confirm or deny any of it. That is the best I can do at this point. If you don't trust "this rumor," that is fair enough. That is why I didn't write it up in my recent post on HemoDoc. I do believe we deserve a full explanation and soon, but I won't hold my breath waiting for an answer from any of these folks any time soon. I hope I am wrong about that, but that is also my gut feeling especially with the new pr campaign NxStage recently launched.

Take care,

Peter
Title: Re: Sak Recall
Post by: Speedy1wrc on July 13, 2014, 07:08:46 PM
Anyone want to know the results of our little bag vs. SAK test? Probably not...

So I started about 7 weeks ago on bags. The goal was simple, to see if my aluminum went down while other controls stayed on SAK's.

Let me say, I am staying off then Pureflow for good now. I think you know where this is going. After 3 weeks my aluminum went from 20 down to 16. After 4 more weeks it is now down to 11. The controls still on SAK's still have high aluminum levels.

Are the SAK'sstill contaminated? We don't know. Or is the bigger question, are they within spec which is just too high? In either case it is clear, being on SAK's even now will make your aluminum level high.

For me the solution is to pitch the Pureflow to the curb. I spoke with Peter at length on the phone and he is done with the Pureflow as well. In speaking with several others, they too are switching.

Hopefully NxStage finally extracts their collective heads from the sand and decide to do something. I would much prefer to use the Pureflow, but at the expense of my health.

What say you?
Title: Re: Sak Recall
Post by: amanda100wilson on July 13, 2014, 07:12:04 PM
I use  Pureflow.  My Aluminium has been fine.  I did use some of the affected SAKS.
Title: Re: Sak Recall
Post by: Hemodoc on July 13, 2014, 11:57:16 PM
Anyone want to know the results of our little bag vs. SAK test? Probably not...

So I started about 7 weeks ago on bags. The goal was simple, to see if my aluminum went down while other controls stayed on SAK's.

Let me say, I am staying off then Pureflow for good now. I think you know where this is going. After 3 weeks my aluminum went from 20 down to 16. After 4 more weeks it is now down to 11. The controls still on SAK's still have high aluminum levels.

Are the SAK'sstill contaminated? We don't know. Or is the bigger question, are they within spec which is just too high? In either case it is clear, being on SAK's even now will make your aluminum level high.

For me the solution is to pitch the Pureflow to the curb. I spoke with Peter at length on the phone and he is done with the Pureflow as well. In speaking with several others, they too are switching.

Hopefully NxStage finally extracts their collective heads from the sand and decide to do something. I would much prefer to use the Pureflow, but at the expense of my health.

What say you?

I am in total agreement. The SAKS allow me better supply control but not at the expense of continued high aluminum. I cannot understand the thinking by NxStage. They don't appear to have learned their lesson yet and that is an expensive lesson on our part. We need a healthy home hemo market. We now have two, we need more to bring about increased access through market competition. I don't see any other way we will increase utilization for home hemo without that aspect. I don't want to see the demise of NxStage, but they are not making good decisions today.
Title: Re: Sak Recall
Post by: Dannyboy on July 14, 2014, 09:00:55 AM
Interesting.  My Aluminum has dropped (but still high)  since discontinuing the recalled SAKs of which I used a bunch.
I have a prejudice against bags, 'cause they seem to take more time/effort to set up, etc. 
However if the SAKs are "infusing me with unreasonable amounts of Aluminum", that is of course another story.

Should have most recent Labs today, curious to see Aluminum level.  In my case I have no "baseline" as it was never checked until the recall.  Sounds like it will be hard to go much below 10 (with Pureflow) from what I'm reading here in this thread.

--Dan

Title: Re: Sak Recall
Post by: Hemodoc on July 14, 2014, 11:44:47 AM
My aluminum levels are up today to 16 from 14. Not dropping. I am sick of this baloney. My Hb is down to 9.5 which is the lowest it has ever been. I am close to needing another dose of iron in the next month as well, but certainly, my levels have changed dramatically as far as how long they last. I believe the aluminum is part of the problem.

I am now approved for bags for the next 6 months. I am getting an emergency shipment this Thursday, so hopefully, no more PureFlow at least until they correct this horrible problem.

I am VERY disappointed in NxStage, VERY. They are just one more for-profit  dialysis corporation.
Title: Re: Sak Recall
Post by: caregivertech1 on July 14, 2014, 01:13:12 PM
I also firmly believe these "in specs" sacs currently in use will result in elevated Aluminum. On 6/17 our aluminum dropped from 20 to 13, then on 7/8 it was up to 17. As I have posted, our aluminum averaged over 20 from Sept. 2013 to Jan. 2014 without using any recalled sacs. These sacs were probably within their 10 microgram limits but infecting my wife to unacceptable levels. I'm sure we'll hear that it takes time to rid the blood of aluminum because it equilabrates from the tissue back into the blood where it can be removed. But if we're getting dosed from the sacs the levels will never go down as we found out last yr. (and now, as well). Also as I've mentioned, we went in-center for a month in Feb. and never got below 10 which lends some credence to the tissue theory. At any rate tissue theory or not if the sacs have 10 mcg we're all in trouble.
Title: Re: Sak Recall
Post by: caregivertech1 on July 14, 2014, 01:25:52 PM
Also my wife has PKD and PKL. I'm not a doc but the common denominator of high Al with our sac users was liver disease.
Title: Re: Sak Recall
Post by: Angiepkd on July 14, 2014, 08:47:47 PM
Also my wife has PKD and PKL. I'm not a doc but the common denominator of high Al with our sac users was liver disease.

I was not aware of any direct correlation between high aluminum levels and liver disease in NxStage patients.  This is very interesting, as I have both Polycystic kidney and Polycystic liver disease.  I would be curious to see some statistics comparing elevated aluminum levels in patients with liver disease to those without liver disease. Maybe the docs will weigh in on this?
Title: Re: Sak Recall
Post by: Speedy1wrc on July 14, 2014, 09:14:21 PM
I'm sure we'll hear that it takes time to rid the blood of aluminum because it equilabrates from the tissue back into the blood where it can be removed. But if we're getting dosed from the sacs the levels will never go down as we found out last yr. (and now, as well). Also as I've mentioned, we went in-center for a month in Feb. and never got below 10 which lends some credence to the tissue theory. At any rate tissue theory or not if the sacs have 10 mcg we're all in trouble.
My level dropped from 20 to 11 in roughly 7 weeks on bags. It has been in the 20 range for a year and a half on SAK's.
Title: Re: Sak Recall
Post by: obsidianom on July 15, 2014, 05:11:58 AM
I'm sure we'll hear that it takes time to rid the blood of aluminum because it equilabrates from the tissue back into the blood where it can be removed. But if we're getting dosed from the sacs the levels will never go down as we found out last yr. (and now, as well). Also as I've mentioned, we went in-center for a month in Feb. and never got below 10 which lends some credence to the tissue theory. At any rate tissue theory or not if the sacs have 10 mcg we're all in trouble.
My level dropped from 20 to 11 in roughly 7 weeks on bags. It has been in the 20 range for a year and a half on SAK's.
I dont buy the liver disease having anything to do with aluminum levels. My wife has the highest aluminum posted here at 40, and has a perfect liver. Her liver is amazing as it can suck up any drug and elininate it quickly. We always have to dose her way up on meds due to her highly effective liver function.
I think this is all about exposure to aluminum and body size. My wife is tiny so her levels are higher.
 
Title: Re: Sak Recall
Post by: Speedy1wrc on July 16, 2014, 05:04:36 PM
Since you mentioned it, I spoke with someone the other night who said their husbands aluminum was 56.
Title: Re: Sak Recall
Post by: Speedy1wrc on July 17, 2014, 01:49:55 PM
OK, more data in. Not only did going onnbags lower my aluminum, by I got my other labs back today. My Hgb jumped 2 to 12.3.

It's a done deal, no more Pureflow.
Title: Re: Sak Recall
Post by: Hemodoc on July 17, 2014, 02:34:58 PM
My aluminum is 16 and my Hb is 9.5. Lowest ever. I hope and pray it goes back up. I am getting IV iron next week. Aluminum prevents hematopoiesis,  which is the bone marrow making blood cell process. It also hinders iron absorption from the GI tract. That is a double hit causing the anemia. My iron levels dropped dramatically in the last 4 months. That is much more so than ordinary.

NxStage no longer deserves our loyalty and trust. In fact, they rank worse than DaVita and FMC in my mind at this point. FMC with the Granuflo incident did make corrections and their product they use today is not hurting folks. We cannot say the same about NxStage essentially lying to us that everything is now fine but it ISN'T Shame on you Joe, shame on you. Say it ain't so Joe, but it is.
Title: Re: Sak Recall
Post by: PrimeTimer on July 17, 2014, 10:24:26 PM
This is all pretty upsetting. They never took a baseline reading when he started dialysis this past fall but my husband is going to insist on having his aluminum level tested NOW. Fortunately, we did not have any of the bad SAKS but the whole issue and the level that IS allowed is upsetting. May be a dumb question but what about their new "S" cycler and doing larger volumes??? Would that mean the more volume, the more aluminum??? Hanging 4 bags on an IV pole and having 1 bag on the warmer is bad enough but how about those needing more than 25 liters per treatment?
Title: Re: Sak Recall
Post by: Hemodoc on July 17, 2014, 10:39:49 PM
I have used 40 liters since my second month on NxStage at home. Yes, more dialysate, more aluminum.
Title: Re: Sak Recall
Post by: PrimeTimer on July 18, 2014, 07:32:19 PM
I have used 40 liters since my second month on NxStage at home. Yes, more dialysate, more aluminum.
That's what I'm afraid of. So whether or not you are a large person or in need of/wanting to run at a higher volume, it's going to be "punishing". THAT really concerns me and it definitely makes you question doing a higher volume to get uh, "better" dialysis...
Title: Re: Sak Recall
Post by: Hemodoc on July 18, 2014, 11:52:17 PM
I have used 40 liters since my second month on NxStage at home. Yes, more dialysate, more aluminum.
That's what I'm afraid of. So whether or not you are a large person or in need of/wanting to run at a higher volume, it's going to be "punishing". THAT really concerns me and it definitely makes you question doing a higher volume to get uh, "better" dialysis...

I would hope you and others don't conflate higher dose dialysis as something bad. No, NxStage aluminum contamination is very bad. High dose dialysis is not. Let's keep the focus where it should be, getting NxStage to clean up their act. In the mean time, I am done with the PureFlow. High dose dialysis is our friend. NxStage right now is not.
Title: Re: Sak Recall
Post by: PrimeTimer on July 19, 2014, 10:52:43 PM
I have used 40 liters since my second month on NxStage at home. Yes, more dialysate, more aluminum.
That's what I'm afraid of. So whether or not you are a large person or in need of/wanting to run at a higher volume, it's going to be "punishing". THAT really concerns me and it definitely makes you question doing a higher volume to get uh, "better" dialysis...

I would hope you and others don't conflate higher dose dialysis as something bad. No, NxStage aluminum contamination is very bad. High dose dialysis is not. Let's keep the focus where it should be, getting NxStage to clean up their act. In the mean time, I am done with the PureFlow. High dose dialysis is our friend. NxStage right now is not.
I agree!
Title: Re: Sak Recall
Post by: PrimeTimer on July 20, 2014, 07:01:47 PM
Curious to know what those of you who are no longer going to use Pureflow/SAKS anymore are going to do. Hang bags? Go back to doing in-center? Use a different home-hemo machine or modality? What about high volume dialysis? We use the NxStage Cycler and still fairly new to this. My concern is that if you want/need to do more than 25 liters of dialysate (25 liters involves hanging 4 bags on the IV pole with a 5th on the warmer), you'd have to (if I'm correct) repeatedly clamp off bags as they empty, remove them from the IV pole and then connect new bags during treatment to do a higher volume. Or is that something we are just going to have to do if we should decide to no longer use Pureflow SAKS? Yikes! 
Title: Re: Sak Recall
Post by: Hemodoc on July 20, 2014, 08:39:35 PM
I have done 40 liters since 2009 hanging bags up until FMC forced me to switch to the PureFlow last year just in time for the aluminum contamination. It is not recommended because of weight and balance issues, but I have done 40 L hanging bags for over 4 years without any problems. Needless to say, you don't try and move the machine once the bags are hung since the weight of the bags is more than the weight of the machine below. But properly balanced, it works. Once again, I am told this is not recommended, but simply my choice on how to dialyze.
Title: Re: Sak Recall
Post by: obsidianom on July 21, 2014, 02:11:37 AM
Curious to know what those of you who are no longer going to use Pureflow/SAKS anymore are going to do. Hang bags? Go back to doing in-center? Use a different home-hemo machine or modality? What about high volume dialysis? We use the NxStage Cycler and still fairly new to this. My concern is that if you want/need to do more than 25 liters of dialysate (25 liters involves hanging 4 bags on the IV pole with a 5th on the warmer), you'd have to (if I'm correct) repeatedly clamp off bags as they empty, remove them from the IV pole and then connect new bags during treatment to do a higher volume. Or is that something we are just going to have to do if we should decide to no longer use Pureflow SAKS? Yikes!
The other option is getting a seperate IV pole to hang extra bags .
Personally I hate the bags . Its a lot more work then pureflow. For now we are sticking with pureflow. I am interested in watching my wifes aluminum monthly for now on it. If it doesnt improve , I might consider the bags. We do 30 liters and hanging 6 bags is a pain.
Title: Re: Sak Recall
Post by: caregivertech1 on July 21, 2014, 05:32:31 AM
There's actually a warmer line for 8 hanging bags. Nxstage number FWS 308......24 to a case. Also they have a stronger pole that doesn't collapse or break down. We're taking aluminum today. If not going down we'll likely go to bags (6-30L).
Title: Re: Sak Recall
Post by: Hemodoc on July 21, 2014, 09:56:33 AM
I use the FWS 209 B warmer bags with the old fashioned warmer on the side, not the top warmer. You can place up to 9 bags on that system. I do a total of 8.
Title: Re: Sak Recall
Post by: Simon Dog on July 21, 2014, 11:16:46 AM
Quote
The other option is getting a seperate IV pole to hang extra bags
Been there, done that, works great.
Title: Re: Sak Recall
Post by: slipkid on July 21, 2014, 02:59:03 PM
I went to hanging bags the day I was notified of the recall.  With Nxstage's silence on the SAK issue (coverup?) and the failure of my unit (Davita) to provide more information about what is going on with the manufacture of the dialysate than what I have learned on this thread, I will not go back to using the SAKs unless and until I am satisfied that aluminum and any other contaminates are below a level I find acceptable. i am using the bags on faith that aluminum is less than the 10 micrograms per liter specification that Nxstage provided to Davita in the letter I posted (now deleted from this thread).

My caregiver and I were sold on the Nxstage system by the relatively ease of using the Pure Flow, although we were not shown nor told how difficult it would be to wrangle a water filled PAK out of the Pure Flow and drag it to our trash been.  I do not normally have the strength to hang 50 ponds of dialysate, and this is left to my wife, which I regret because she already has enough to do.  In addition, we now have an enormous inventory of boxes we are forced to store.

Tomorrow, I get results of July blood tests, so we shall see what effect of using the bags has had on serum aluminum.  June tests showed a couple of points drop, which I considered to be not statistically significant.

Title: Re: Sak Recall
Post by: slipkid on July 21, 2014, 03:20:54 PM
@ Hemodoc

I have read a Nxstage document, that I can not at the moment put may hands on, that use of the Pure Flow was an optional accessory to use of the Nxstage therapy system.  How did FMC force you to use the PureFlow?  I appreciate that the issue is now moot.
Title: Re: Sak Recall
Post by: Hemodoc on July 21, 2014, 03:35:03 PM
@ Hemodoc

I have read a Nxstage document, that I can not at the moment put may hands on, that use of the Pure Flow was an optional accessory to use of the Nxstage therapy system.  How did FMC force you to use the PureFlow?  I appreciate that the issue is now moot.

I moved from CA with Kaiser to Idaho. Even though I THOUGHT in my interactions with them that they had already accepted me with my prior treatment of 40 liters hanging bags, they informed me that they would not accept me unless I agreed to go to the PureFlow. Also, I am now a Group Health patient and no longer a Kaiser patient. Yes, they held me to blackmail essentially. 

In the end it was a matter of shipment costs for bags that are more than shipping the PureFlow; concentrated SAKs. So, yes, they gave me little option. I had been going to a DaVita unit while here on a temporary basis each year but they told me that DaVita had dosage protocols. In the end, I probably could have stayed on Bags with DaVita 45 minutes away, but at a lower dosage. I chose to do the PureFlow at the same dosage.

Now I am back to bags, but that is for "6 months" only at this point. I will have to fight the battle again 6 months down the road. I am sick of for-profit dialysis units plain and simple.
Title: Re: Sak Recall
Post by: Speedy1wrc on July 21, 2014, 04:18:13 PM
I run 30L on the solid pole with one bag on the Express warmer. It's heavy and I have to be careful moving it. It's a bit top heavy. Indeed I use the mulriline adapter which for some odd reason on our order form is listed as waste line extensions.

I am done with the Pureflow forever.

The only other option here in the US is the babyK. That is until the Baxter machine is approved and/or another technology emerges. But for now the choices are limited. I would never go back in center. Once I started seeing how many things they were doing wrong I thanked my lucky stars I am still alive. A friend who was at that same clinic wasn't as lucky. Home hemo as a modality has helped my overall health. I do mostly feel better other than the aluminum symptoms.
Title: Re: Sak Recall
Post by: slipkid on July 21, 2014, 04:49:15 PM
@ Hemodoc

The only satisfaction I am getting from this situation is the costs of the bags and shipping will eat into Nxstage's profits.

@ speedy

I will likewise never go back to in-center.  We are all between a rock and a hard place.  We need the choice of other in-home dialysis modalities desperately.
Title: Re: Sak Recall
Post by: PrimeTimer on July 21, 2014, 05:39:32 PM
There's actually a warmer line for 8 hanging bags. Nxstage number FWS 308......24 to a case. Also they have a stronger pole that doesn't collapse or break down. We're taking aluminum today. If not going down we'll likely go to bags (6-30L).
This is good to know, thanks! I might inquire about getting those to keep in our inventory and especially if we end up having to forego using the Pureflow SAKS because of aluminum issues. I don't know if we have the most current model of the IV pole, the one we have came in 2 pieces, sits on a sort of small square hard plastic stand while also screwed/bolted to the back of the cycler. We have the Express Warmer that sits on-top.

My husband sees his Neph on Thursday and hopefully agrees to testing his aluminum level. If not at clinic, then when I do next month's labs at home. Once we know what his aluminum level is, I'll post it. We never got any of the "bad" SAKS but since his baseline was never taken, we definitely want to know what his level is at.
Title: Re: Sak Recall
Post by: Hemodoc on July 21, 2014, 05:56:49 PM
@ Hemodoc

The only satisfaction I am getting from this situation is the costs of the bags and shipping will eat into Nxstage's profits.

@ speedy

I will likewise never go back to in-center.  We are all between a rock and a hard place.  We need the choice of other in-home dialysis modalities desperately.

Actually, FMC is eating up the costs,  not NxStage, but yes, we are in between a rock and hard place. How soon the FDA will approve the Baxter Vivia is completely unknown at this time. We can hope for soon, but the FDA is not known for worrying about us that need these new technologies.

At least it was CE Mark approved last year which is the European equivalent of the FDA.

Title: Re: Sak Recall
Post by: Speedy1wrc on July 21, 2014, 07:22:55 PM
The two piece pole is the travel pole. Why it exists I am not sure. It doesn't hold as much weight as the solid pole. If I recall I was told it holds either 20 or 25 liters. I don't remember exactly. If you use 30 L at home with the solid pole you will still need 30 L traveling.
Title: Re: Sak Recall
Post by: amanda100wilson on July 22, 2014, 02:17:58 PM
I can hang 25 liters on my travel pole, but you do need to make sure that they hang towards the front hangers.  I think that if you put any more on the hangers at the back, you would probably risk counter-balancing the machine and it would tip.
Title: Re: Sak Recall
Post by: caregivertech1 on July 22, 2014, 05:28:25 PM
There's actually a warmer line for 8 hanging bags. Nxstage number FWS 308......24 to a case. Also they have a stronger pole that doesn't collapse or break down. We're taking aluminum today. If not going down we'll likely go to bags (6-30L).
This is good to know, thanks! I might inquire about getting those to keep in our inventory and especially if we end up having to forego using the Pureflow SAKS because of aluminum issues. I don't know if we have the most current model of the IV pole, the one we have came in 2 pieces, sits on a sort of small square hard plastic stand while also screwed/bolted to the back of the cycler. We have the Express Warmer that sits on-top.

My husband sees his Neph on Thursday and hopefully agrees to testing his aluminum level. If not at clinic, then when I do next month's labs at home. Once we know what his aluminum level is, I'll post it. We never got any of the "bad" SAKS but since his baseline was never taken, we definitely want to know what his level is at.


Yeah, we didn't have any "bad" saks either before June 2013 after my wife's aluminum had already skyrocked to 28 on their "good" saks.
Title: Re: Sak Recall
Post by: Speedy1wrc on July 22, 2014, 07:27:47 PM
There were a few of us whose aluminum rose before the recalled SAK's. The question was always, did they have more bad SAK's that we just didn't know about? However now with the latest data it appears that it is just the spec level is/waw too high to begin with. As long as they keep the same spec nothing will change for those patients who are seeing the elevated levels.
Title: Re: Sak Recall
Post by: slipkid on July 22, 2014, 08:47:08 PM
Today's aluminum chem report shows Al has dropped to 16 mg/l.  This is 10 point drop from mid-May levels.  Moving in right direction.

Symptoms:  Identifiable improvement in dry, flaky skin on forearms and calves. Other symptoms indeterminate.

As speedy has said, how low will Al levels go, even with use of hanging bags?
Title: Re: Sak Recall
Post by: obsidianom on July 23, 2014, 09:16:38 AM
My wifes aluminum only dropped from 40 to 39. We are still using pureflow so I am not happy. I am considering asking about using hanging bags .
This is really frustrating.
Title: Re: Sak Recall
Post by: Speedy1wrc on July 23, 2014, 09:39:10 AM
Bags are a pain no question about it. But, as more and more are finding out there levels aren't dropping on the Pureflow. Without a ready alternative it's the lesser of two evils. Hopefully sooner than later another option will be available.
Title: Re: Sak Recall
Post by: Hemodoc on July 23, 2014, 03:46:36 PM
My wifes aluminum only dropped from 40 to 39. We are still using pureflow so I am not happy. I am considering asking about using hanging bags .
This is really frustrating.

Dr. O,

You have no choice but to go to the bags or go to the Baby K. The SAKs are still full of aluminum. NxStage has gone down the tubes and taking us with them. This is the most unethical thing I have ever encountered in my years on dialysis.
Title: Re: Sak Recall
Post by: obsidianom on July 25, 2014, 06:46:17 AM
I screwed up the numbers. My wifes aluminum dropped from 44 to 39. So we are making slow progress. that was in 3 weeks. So we will moniter every month . As long as it keeps dropping I will hang onto the pureflow. She is doing fairly well , so i dont want to rock the boat. I hate hanging bags.
Title: Re: Sak Recall
Post by: PrimeTimer on July 25, 2014, 07:20:41 AM
I wonder how much aluminum is added to our city tap water. I've read that it is a requirement for city water treatment plants to put aluminum in the water as part of the water-treatment process. This made me wonder how much aluminum we drink on a daily basis. My husband and I drink tap water, we can't afford bottled water or a fancy purifier on our kitchen faucet so we drink straight from the tap. In no way am I condoning what NxStage did as far as the "bad SAK's" are concerned but, I am wondering what their reason is for having aluminum in the SAK's and if it's possibly the same reason that city treatment plants have.

Whenever I make a new "batch" for the SAK's, I test for chloramines. Obviously the PAK does a good job at removing chlorine because the SAK's always pass the test. But for the heck of it, I've taken a tester strip to our tap water and oh boy...LOTS of chlorine shows up on the tester strip. Kind of gives me a sense of relief knowing that the PAK has removed most of the chlorine from the SAK's. Anyway, made me think about this issue of aluminum and what purpose it has being in the SAK's and if it's all for the same reasons why aluminum is added to city water. Maybe NxStage can't bring the level down any further (maybe the city can't either) than they do or if they could, maybe it would mean risking some other kind of contamination.
Title: Re: Sak Recall
Post by: obsidianom on July 25, 2014, 09:09:27 AM
I have the test reults done on our well water and thfinal pak treated water.  Well water was high aluminum at .238 mg/liter.  It should be under .01.
The treated Pak water was down to an excellant .008 mg /liter. The standard calls for under .01  , so the PAK did its job well. It took my high aluminum water and brought it down to excellant levels.
This brings it down to the fact thier own PAK technology works to reduce aluminum in water. They can do it.
What occurred is that Pisa uses Purac to make the lactate. They make the solution bags . Rockwell took over the saks and did not use purac. They used a company in the US that I wont name but is not Purac. (I know the name but cant name them for legal reasons). Purac is the Gold standard in lactate . They are the best. This other company is not at their level and so we all got nailed. Before Rockwell Pisa made the saks concentrate.
According to Dr. Agar oral aluminum is not an issue as the gut blocks a lot of the absorbtion. So drinking water is not the issue . It requires direct blood to dialysate contamination to get the blood levels to rise. that is what we had. 
Title: Re: Sak Recall
Post by: Hemodoc on July 25, 2014, 10:45:12 AM
Dear Prime Timer,

No, it is not an issue of not being able to reach only trace levels. Purac, the original source of lactate in all NxStage products prior to the Rockwell agreement in early  2013 makes pharmaceutical grade lactate with aluminum reduced to 0.1 ppm which is 0.11 mcg/liter.

Rockwell with an alleged outside producer had VERY high levels of aluminum in the concentrate. Remember, it is diluted to a level of 11-13 mcg/liter, but is MUCH higher in the concentrated SAK before you add the water making a batch.

That is over 100 times higher aluminum levels than the Purac which remember will be diluted further by the dialysate and be lower than 0.11 mcg liter. We may be looking at a 1000 fold difference in the final product. NxStage is not listing the aluminum content in their prior solutions so that is a bit of speculation, but probably closer to the real answer. I would like to have all of the actual numbers, but I am left only with the Purac number prior to adding to the rest of the dialysate and the FDA recall letter. But I believe it is a 1000 fold difference in the two final products as logic would dictate. In the very least it is a 100 time difference in levels.

I am not aware of aluminum being an issue in any other dialysate products which should be readily removed in an RO system. Chlorine is removed by a carbon filter system but not in the RO. That is why in-center has both carbon filters and RO systems.
Title: Re: Sak Recall
Post by: slipkid on July 25, 2014, 10:47:58 AM
message posted to wrong thread.
Title: Re: Sak Recall
Post by: caregivertech1 on July 25, 2014, 11:33:18 AM
I'd like to hear comments on something I stumbled upon that would reduce aluminum levels without hanging 5 or 6 bags. We recently switched over from 25L to 30L(thanks to the suggestions on this board). To use up the 307(50L..2 treatments) inventory, I had a 5L bag on the warmer ready to go when the cycler read 25L to go. I simply hit stop, clamped the green clamps and switched dialysate line from the pureflow to the bag and hit treatment. It takes 30 seconds. So, we got 30L of treatment..the last 5 aluminum free. We did this for several weeks and our aluminum level dropped to 13 from the high teens and low 20's. When we went to sac 302 (60L...2 treatments) with no bags the aluminum went back up to 17. I'm willing to bet if I use say 2 bags of aluminum free dialysate as the final 10L of our 30L treatment, we might get to 10 mcg or better. This would be a compromise  if you're having trouble getting bags authorized. You could actually work out of your "reserve" bag inventory. I can't believe it's come to this but the switch to bags during treatment is very easy.
Title: Re: Sak Recall
Post by: caregivertech1 on July 25, 2014, 02:31:01 PM
Correction to above post: When the cycler indicated "5L" remaining hit stop and connect the bag.
Title: Re: Sak Recall
Post by: Hemodoc on July 25, 2014, 03:55:23 PM
Correction to above post: When the cycler indicated "5L" remaining hit stop and connect the bag.

Why compromise your health by using the SAKs at all. Let's get NxStage to STOP poisoning us. I mean, for real, that is what they are doing. Unbelievable is all I can say. This NEEDS to stop immediately.
Title: Re: Sak Recall
Post by: obsidianom on July 26, 2014, 08:29:02 AM
Int Urol Nephrol. 2014 Jul;46(7):1361-5. doi: 10.1007/s11255-014-0752-8. Epub 2014 Jun 18.

Aluminum transfer during dialysis: a systematic review.

Mardini J1, Lavergne V, Ghannoum M.
Author information
Abstract
PURPOSE:

Dialysis-dependent patients are particularly susceptible to the toxic effects of aluminum (Al) because of their impaired ability to eliminate it. Al contamination of dialysis fluid remains a threat in this population. The mechanism for Al diffusion across dialysis membranes is not well established. Our objective is to verify, in AL-exposed patients, the postulate that the direction of Al transfer is predicted by the concentration gradient between free diffusible plasma Al and dialysate Al.

METHODS:

A systematic review of the literature was performed. Only papers which included Al plasma concentration ([Al]p), Al dialysate concentration ([Al]d) and direction of Al transfer (positive = from dialysate to plasma, negative = from plasma to dialysate) were selected. We also included four patients from our own cohort. Assuming that [Al]p has an ultrafiltrable fraction between 17 and 23 %, cases were considered in keeping with our hypothesis if any of the following scenarios was present: negative Al transfer when [Al]d < [Al]p*23 % and positive Al transfer when [Al]d > [Al]p*17 %.

RESULTS:

The search yielded 409 articles, of which 12 were selected for review. When reviewing individual patients for analysis, 108 out of 115 (94 %) patients followed our hypothesis. By further excluding cases in which Al transfer could not be determined, only three out of 111 patients were contrary to out hypothesis.

CONCLUSION:

Comparing ultrafiltrable Al to dialysate Al permits to accurately predict the direction of Al transfer. The optimal [Al]d should be <20 % of the maximally acceptable [Al]p. In order to follow K/DOQI guidelines ([Al]p < 20 μg/L), the [Al]d should therefore not exceed 4 μg/L. At the level presently supported by K/DOQI ([Al]d < 10 μg/L), [Al]p could realistically reach 50 μg/L and potentially cause toxicity.
Title: Re: Sak Recall
Post by: Hemodoc on July 26, 2014, 11:41:47 AM
Dr O, I read this article a while back and it truly bothers me as well. Why, we can produce products that are essentially aluminum free. Why then are we even setting a limit of 4? Why not go with 0.1 ppm (0.11 mcg/L) that Purac obtains in their pharmaceutical grade lactate products?

They are asking the wrong question. What level of aluminum can cause problems? It appears to me with a level of 16 and symptomatic with low Hb and diminished mental capacity, that is way TOO HIGH. Why have ANY aluminum.

Sorry, but this article is just blowing smoke from you know where and looking at the wrong answer in their question right from the beginning.
Title: Re: Sak Recall
Post by: PrimeTimer on July 26, 2014, 11:56:04 AM
The NxStage Online Dosing Calculator appears to require a physician's license to be entered. People are going to need to ask their doctors to do this for them.

As for increasing dialysate per treatment for instance, to 40-50 liters, those using the Pureflow SAK's wanting to avoid aluminum will need to hang 8-10 of the Pre-Mixed Bags instead. And regardless of whether or not anyone wants to increase their dialysate, if they want to avoid aluminum and are using Pureflow SAK's, they will need to have their doctor rewrite their prescriptions so they may use Pre-Mixed Bags. As for those doing in-center, I suppose they do not have to worry about aluminum so, that would be another option for those using Pureflow SAK's wanting to avoid aluminum. Much to decide. Good luck everyone.
Title: Re: Sak Recall
Post by: obsidianom on July 26, 2014, 12:40:19 PM
This is an interesting article. I cant recommend melatonin just from this article but melatonin has shown many positive effects in humans anyway. Perhaps this is another.

Food Chem Toxicol. 2014 Aug;70:84-93. doi: 10.1016/j.fct.2014.03.043. Epub 2014 Apr 12.

Effects of melatonin on aluminium-induced neurobehavioral and neurochemical changes in aging rats.

Allagui MS1, Feriani A2, Saoudi M2, Badraoui R3, Bouoni Z2, Nciri R2, Murat JC4, Elfeki A2.
Author information

Abstract

This study aimed to investigate the potential protective effects of melatonin (Mel) against aluminium-induced neurodegenerative changes in aging Wistar rats (24-28months old). Herein, aluminium chloride (AlCl3) (50mg/kg BW/day) was administered by gavage, and melatonin (Mel) was co-administered to a group of Al-treated rats by an intra-peritoneal injection at a daily dose of 10mg/kg BW for four months. The findings revealed that aluminium administration induced a significant decrease in body weight associated with marked mortality for the old group of rats, which was more pronounced in old Al-treated rats. Behavioural alterations were assessed by 'open fields', 'elevated plus maze' and 'Radial 8-arms maze' tests. The results demonstrated that Mel co-administration alleviated neurobehavioral changes in both old and old Al-treated rats. Melatonin was noted to play a good neuroprotective role, reducing lipid peroxidation (TBARs), and enhancing enzymatic (SOD, CAT and GPx) activities in the brain organs of old control and old Al-treated rats. Mel treatment also reversed the decrease of AChE activity in the brain tissues, which was confirmed by histological sections. Overall, the results showed that Mel administration can induce beneficial effects for the treatment of Al-induced neurobehavioral and neurochemical changes in the central nervous system (CNS).
Title: Re: Sak Recall
Post by: Angiepkd on July 27, 2014, 07:17:23 PM
I took melatonin for sleep issues during my time on D. I was prescribed 3mg tablets taken once daily before bed. I feel like I still suffered many of the neurological symptoms of high aluminum levels.  Not sure if these were all due to aluminum, though, as many symptoms are similar to those caused by kidney failure and D.  Interesting theory.  Maybe my symptoms would have been worse without the melatonin.
Title: Re: Sak Recall
Post by: Maggie and Jeff on July 29, 2014, 11:06:14 AM
I've been out of the loop for awhile.

Maggie's AL when up while using Saks this last month.

We AAMI tested 2 Sak lots and one Hanging bag lot

Both the Saks tested .005

The Hanging bags tested >.005

We are switching to hanging bags.
Title: Re: Sak Recall
Post by: Simon Dog on July 29, 2014, 12:44:43 PM
I've been out of the loop for awhile.

Maggie's AL when up while using Saks this last month.

We AAMI tested 2 Sak lots and one Hanging bag lot

Both the Saks tested .005

The Hanging bags tested >.005

We are switching to hanging bags.
Is there a typo?  You are reporting the bags tested higher than the saks.
Title: Re: Sak Recall
Post by: Maggie and Jeff on July 31, 2014, 08:54:37 AM
I've been out of the loop for awhile.

Maggie's AL when up while using Saks this last month.

We AAMI tested 2 Sak lots and one Hanging bag lot

Both the Saks tested .005

The Hanging bags tested >.005

We are switching to hanging bags.
Is there a typo?  You are reporting the bags tested higher than the saks.

No typo 2 SAK lots showed .005
The hanging bags showed less than (>).005

I think .005 is the lowest the AAMI test goes so the SAKs are showing they are equal to .005 and the hanging bags are showing less than the .005
Title: Re: Sak Recall
Post by: Simon Dog on July 31, 2014, 09:59:28 AM
No typo 2 SAK lots showed .005
The hanging bags showed less than (>).005
Where I come from, ">" means greater than and "<" means less than.
Title: Re: Sak Recall
Post by: noahvale on July 31, 2014, 10:42:13 AM
*
Title: Re: Sak Recall
Post by: Simon Dog on July 31, 2014, 10:59:32 AM
No matter where anyone is from, the universal symbol for LESS THAN is "<" and GREATER THAN ">"  This might help to remember:
You mean it's not like driving on the right side of the road vs. driving on the left, or a right hand vs. left hand stereoisomer  :rofl;
Title: Re: Sak Recall
Post by: Maggie and Jeff on August 01, 2014, 10:42:13 AM
Ya'll are correct. :oops;  I never said I was any good at math. :shy;

<.005 for the hanging bags

I'll scan in the print out when I have time and post it
Title: Re: Sak Recall
Post by: PrimeTimer on August 04, 2014, 06:57:39 PM
Question:  Due to the aluminum toxicity issue with Pureflow SAK's, we told my husband's Neph that we want his aluminum level tested and she said she would order it. We do his monthly labs at home and take it to the clinic (Fresenius). The clinic then sends it to Spectra. My question is, does anyone know if his aluminum level can be tested using one of the usual monthly test tube vials or does/should it involve a whole separate vial of blood to be drawn? We normally draw "pre" dialysis: Tiger tube and Lavender and the Gold "post" dialysis. We plan on calling the center tomorrow during business hours to find out but thought I'd ask if anyone on here knows. Thanks. 
Title: Re: Sak Recall
Post by: noahvale on August 04, 2014, 07:40:21 PM
^
Title: Re: Sak Recall
Post by: PrimeTimer on August 04, 2014, 10:50:46 PM
Question:  Due to the aluminum toxicity issue with Pureflow SAK's, we told my husband's Neph that we want his aluminum level tested and she said she would order it. We do his monthly labs at home and take it to the clinic (Fresenius). The clinic then sends it to Spectra. My question is, does anyone know if his aluminum level can be tested using one of the usual monthly test tube vials or does/should it involve a whole separate vial of blood to be drawn? We normally draw "pre" dialysis: Tiger tube and Lavender and the Gold "post" dialysis. We plan on calling the center tomorrow during business hours to find out but thought I'd ask if anyone on here knows. Thanks.

You will need a separate dark blue top tube and best drawn pre-dialysis.  Also, you should not take vitamins or mineral supplements a couple of days before the blood draw. 

Spectra, like most labs used by dialysis centers, send the blood elsewhere to be tested.  -  http://www.spectra-labs.com/laboratories-test-menu#search

Thanks, noahvale! ONCE AGAIN, someone on this site comes thru! Guess I will be going down to the clinic tomorrow to get the blue tube but not before I call them to ask why they didn't give it to us in the first place. It's been a few weeks since my husband's last appt when the Neph said she'd order the aluminum test and here we are, "monthly lab time" BUT....no one told us that it would be a separate tube and they also failed to mention anything about not taking vitamins/mineral supplements for a few days prior to the test. Sure wish I had asked this question sooner (and now I am going on a rant)   :rant; but you'd think that when a doctor says they are going to order a test, they WOULD ORDER THE TEST!! And the fact that this involves testing for aluminum poisoning really P---sses me off! 'nuff said. 

I may have been born at night but, I wasn't born last night!  :stressed;
Title: Re: Sak Recall
Post by: Speedy1wrc on August 06, 2014, 12:21:18 PM
Nothing new to add, but yes a special dark blue top. The top is aluminum free so there is no cross contamination. Since the recall I have been getting a dark blue tube every month for rhe forseeable future. Just did labs today and am anxious to see how low my levels have dropped.
Title: Re: Sak Recall
Post by: PrimeTimer on August 07, 2014, 01:57:30 AM
There's actually a warmer line for 8 hanging bags. Nxstage number FWS 308......24 to a case. Also they have a stronger pole that doesn't collapse or break down. We're taking aluminum today. If not going down we'll likely go to bags (6-30L).

caregivertech1: Thanks for including the item number for the warmer line for 8 hanging bags (FWS308) in case my husband's aluminum level comes back too high and we decide to hang bags. But, in speaking with NxStage today, the new "S" cycler we are getting cannot be ran at higher ultrafiltration or volume rates using bags...only with Pureflow 400 Series SAK's. But they did say we can run at the same (slower) rates we were using on the System One Cycler using the bags. My guess, is that at a faster rate the dialysate wouldn't have the chance to get warmed up enough passing thru the warming bag and could cause patient discomfort, injury or even hyperthermia. Anyways, I pray we do not have to use bags but if my husband's aluminum level comes back too high...oh well...there goes the Pureflow machine...  :'( Would also be quite angering!  >:(
Title: Re: Sak Recall
Post by: caregivertech1 on August 07, 2014, 06:19:50 AM

Also, if you want to use the Nxstage dose calculator just put in a phone number when it asks for your medical #. It worked for me and I've been using it to actually lower our speeds.
Title: Re: Sak Recall
Post by: PrimeTimer on August 07, 2014, 11:51:50 PM

Also, if you want to use the Nxstage dose calculator just put in a phone number when it asks for your medical #. It worked for me and I've been using it to actually lower our speeds.

Thanks, might give that a try.
Title: Re: Sak Recall
Post by: Maggie and Jeff on August 08, 2014, 12:20:51 PM

Also, if you want to use the Nxstage dose calculator just put in a phone number when it asks for your medical #. It worked for me and I've been using it to actually lower our speeds.

Thanks, might give that a try.

Worked for me.
Title: Re: Sak Recall
Post by: caregivertech1 on August 08, 2014, 02:53:43 PM
FYI. wife's AL dropped to 12 from 17(was in the 20's) 2 weeks ago. Started again using one 5L bag for the final 5L So that's 25L of contaminated pureflow and 5L of "clean" dialysate. Others in our clinic are still around 20. When you think about it that last 5L cleans twice the blood  volume of the body at 350Qb and just maybe removes the AL contamination from the pureflow before it combines with protein which is a much larger molecule. All bags is the way to go but until I can get there this may be working. Thinking about 10L now...one on the warmer and one hanging. Another AL test in 2 weeks.
Title: Re: Sak Recall
Post by: Maggie and Jeff on August 08, 2014, 07:20:44 PM
We switched to hanging bags we shall see what what the labs say.

Bye bye pureflow.
Title: Re: Sak Recall
Post by: PrimeTimer on August 21, 2014, 09:03:40 AM
Question:  Due to the aluminum toxicity issue with Pureflow SAK's, we told my husband's Neph that we want his aluminum level tested and she said she would order it. We do his monthly labs at home and take it to the clinic (Fresenius). The clinic then sends it to Spectra. My question is, does anyone know if his aluminum level can be tested using one of the usual monthly test tube vials or does/should it involve a whole separate vial of blood to be drawn? We normally draw "pre" dialysis: Tiger tube and Lavender and the Gold "post" dialysis. We plan on calling the center tomorrow during business hours to find out but thought I'd ask if anyone on here knows. Thanks.

You will need a separate dark blue top tube and best drawn pre-dialysis.  Also, you should not take vitamins or mineral supplements a couple of days before the blood draw. 

Spectra, like most labs used by dialysis centers, send the blood elsewhere to be tested.  -  http://www.spectra-labs.com/laboratories-test-menu#search

Anyone being told by Fresenius that they no longer test for aluminum at their center because Spectra no longer performs the test? My husband's Neph didn't know that either so wrote him a "prescription" for the test and told him he will have to take it to a lab on his own to have his aluminum level tested and...to be prepared because it could cost upward of $500. Needless to say, I am quite upset about this and concerned over the fact that this was all brought up with the Neph last month and only now are they getting around to telling my husband that their center "no longer covers/performs" aluminum tests. My husband uses the NxStage cycler and altho he did not use any of the contaminated SAKS on the Recall List, he does use SAKS and now come to find out, Fresenius never even took his baseline aluminum level when he began dialysis last September, so we have no idea what his aluminum level was before using SAKS and certainly do not know now and Fresenius will not test for it. Hhmm...
Title: Re: Sak Recall
Post by: noahvale on August 21, 2014, 10:03:06 AM
*
Title: Re: Sak Recall
Post by: PrimeTimer on August 21, 2014, 11:42:29 AM

Anyone being told by Fresenius that they no longer test for aluminum at their center because Spectra no longer performs the test? My husband's Neph didn't know that either so wrote him a "prescription" for the test and told him he will have to take it to a lab on his own to have his aluminum level tested and...to be prepared because it could cost upward of $500. Needless to say, I am quite upset about this and concerned over the fact that this was all brought up with the Neph last month and only now are they getting around to telling my husband that their center "no longer covers/performs" aluminum tests. My husband uses the NxStage cycler and altho he did not use any of the contaminated SAKS on the Recall List, he does use SAKS and now come to find out, Fresenius never even took his baseline aluminum level when he began dialysis last September, so we have no idea what his aluminum level was before using SAKS and certainly do not know now and Fresenius will not test for it. Hhmm...



You can contact Charlonda Thrower, Patient Services Director for ESRD Network 14:

Patient Services Director
Charlonda Thrower, BA, LMSW
469-916-3808
972-503-3215 Ext. 324
email: cthrower@nw14.esrd.net

Patient and renal professional concerns/grievances
Decreasing patient conflict/Involuntary patient discharge
VocRehab/Advance care planning/End of Life
Quality control audits with results to MRB

If not familiar with the ESRD Network system, read this thread recently posted by Meinuk:

http://ihatedialysis.com/forum/index.php?topic=31444.msg475263;boardseen#new

For specific info on ESRD Network 14 which covers Texas:  http://www.esrdnetwork.org/

This page gives full staff info: http://www.esrdnetwork.org/network/who-we-are/staff.asp

noahvale: Thank you very much for the info and providing the links! I will save them. Hopefully we won't have to escalate this any further...We are taking the prescription order that the Neph wrote to a lab tomorrow that is covered by our insurance so that he can have his aluminum blood level tested. By the way, I called Spectra and they DO perform the aluminum test (and just like you said, it's the test tube with a royal-blue colored top). They said all the center would have had to do, was attach the Neph's orders to the correct requisite form, draw the blood and they will test it. I also called our insurance company and THEY TOO said that the aluminum test is covered and that Spectra is in our network. Of course, we already knew they were because that is where Fresenius has been shipping the monthly labs that I draw here at home. This is why I wish Fresenius would have given us the test tube so that we could have already tested his aluminum level by now. But nope. They said THEY would have to perform the test THEMSELVES at his appt, which was TODAY. This has been brought up with them for over a month and then to find out at his appt today that they "don't do the test" because they are not covered for it (after telling him they would perform the test), really burns me up!! Anyway, my husband is too afraid to rock the boat with them so like I said, we are going to have his aluminum tested at a lab that is covered by our insurance. What an ordeal!! And now we have to wait even longer to find out what his aluminum level is. Even the insurance company was shocked that the center did not handle this for us, if that tells you anything.  :stressed;
Title: Re: Sak Recall
Post by: obsidianom on August 21, 2014, 12:52:16 PM
Question:  Due to the aluminum toxicity issue with Pureflow SAK's, we told my husband's Neph that we want his aluminum level tested and she said she would order it. We do his monthly labs at home and take it to the clinic (Fresenius). The clinic then sends it to Spectra. My question is, does anyone know if his aluminum level can be tested using one of the usual monthly test tube vials or does/should it involve a whole separate vial of blood to be drawn? We normally draw "pre" dialysis: Tiger tube and Lavender and the Gold "post" dialysis. We plan on calling the center tomorrow during business hours to find out but thought I'd ask if anyone on here knows. Thanks.

You will need a separate dark blue top tube and best drawn pre-dialysis.  Also, you should not take vitamins or mineral supplements a couple of days before the blood draw. 

Spectra, like most labs used by dialysis centers, send the blood elsewhere to be tested.  -  http://www.spectra-labs.com/laboratories-test-menu#search

Anyone being told by Fresenius that they no longer test for aluminum at their center because Spectra no longer performs the test? My husband's Neph didn't know that either so wrote him a "prescription" for the test and told him he will have to take it to a lab on his own to have his aluminum level tested and...to be prepared because it could cost upward of $500. Needless to say, I am quite upset about this and concerned over the fact that this was all brought up with the Neph last month and only now are they getting around to telling my husband that their center "no longer covers/performs" aluminum tests. My husband uses the NxStage cycler and altho he did not use any of the contaminated SAKS on the Recall List, he does use SAKS and now come to find out, Fresenius never even took his baseline aluminum level when he began dialysis last September, so we have no idea what his aluminum level was before using SAKS and certainly do not know now and Fresenius will not test for it. Hhmm...
Thats weird because we are at Fresenius clinic and we are testing my wifes aluminum every month. No problems at all with it. We just got our latest and it was still up at 36 . She was at 44 so it is SLOWLY dropping. 
Yesterday we got the ok to test our actual dialystate from the sak. We are testing aluminum , and all the other levels such as potasium , sodium , etc. This will tell us if the aluminum is fixed and if the saks are actually giving the exact levels of electrolytes they claim. WE drew it yesterday and should have the results in a week. This should be VERY interesting.
Title: Re: Sak Recall
Post by: PrimeTimer on August 21, 2014, 01:35:59 PM
Question:  Due to the aluminum toxicity issue with Pureflow SAK's, we told my husband's Neph that we want his aluminum level tested and she said she would order it. We do his monthly labs at home and take it to the clinic (Fresenius). The clinic then sends it to Spectra. My question is, does anyone know if his aluminum level can be tested using one of the usual monthly test tube vials or does/should it involve a whole separate vial of blood to be drawn? We normally draw "pre" dialysis: Tiger tube and Lavender and the Gold "post" dialysis. We plan on calling the center tomorrow during business hours to find out but thought I'd ask if anyone on here knows. Thanks.

You will need a separate dark blue top tube and best drawn pre-dialysis.  Also, you should not take vitamins or mineral supplements a couple of days before the blood draw. 

Spectra, like most labs used by dialysis centers, send the blood elsewhere to be tested.  -  http://www.spectra-labs.com/laboratories-test-menu#search

Anyone being told by Fresenius that they no longer test for aluminum at their center because Spectra no longer performs the test? My husband's Neph didn't know that either so wrote him a "prescription" for the test and told him he will have to take it to a lab on his own to have his aluminum level tested and...to be prepared because it could cost upward of $500. Needless to say, I am quite upset about this and concerned over the fact that this was all brought up with the Neph last month and only now are they getting around to telling my husband that their center "no longer covers/performs" aluminum tests. My husband uses the NxStage cycler and altho he did not use any of the contaminated SAKS on the Recall List, he does use SAKS and now come to find out, Fresenius never even took his baseline aluminum level when he began dialysis last September, so we have no idea what his aluminum level was before using SAKS and certainly do not know now and Fresenius will not test for it. Hhmm...
Thats weird because we are at Fresenius clinic and we are testing my wifes aluminum every month. No problems at all with it. We just got our latest and it was still up at 36 . She was at 44 so it is SLOWLY dropping. 
Yesterday we got the ok to test our actual dialystate from the sak. We are testing aluminum , and all the other levels such as potasium , sodium , etc. This will tell us if the aluminum is fixed and if the saks are actually giving the exact levels of electrolytes they claim. WE drew it yesterday and should have the results in a week. This should be VERY interesting.

Yes, your test results will be VERY interesting. Hope it turns out okay. I think my husband's Neph was a bit caught off-guard this morning because when my husband brought up the aluminum test (again), she looked at the nurse and said "I thought I ordered that last month", as if to be saying "why wasn't it done, where is it??" And the nurse snapped "we don't do that test here anymore". And the same nurse then turned to my husband and asked "why do want your aluminum tested anyway?" (As if it's her business or even up to her). He then went on to explain to her that aluminum is found in many things, including the dialysate in the SAKS and that since people with kidney disease are unable to eliminate it, it can build up in their system and so their aluminum level should be monitored. At that point, the Neph kind of gave the nurse an angry look and let out a little huff and proceeded to write my husband a prescription order to have his aluminum level tested at a lab of his choosing but, added that it could be very expensive. Luckily, our insurance will cover it. The fact that the nurse said that they (the center) doesn't perform aluminum level tests ANYMORE begs the question, "when did they STOP testing for it???" Hhmm...I'd be curious to know if they stopped testing for it around the same time of the SAK recall...perhaps I am just being overly sensitive but I smell something fishy and I do not like it. My radar is going off like crazy, you could say I have a nose for these things and I'm telling you, something does not smell right. But...my husband (the patient) doesn't want us (me) rocking the boat with his center so I am going to honor his wishes. It's his body, his decision. But still, I wish I could call the center and make them explain themselves as far as telling me they would do the aluminum test and then telling my husband no. Seems they are unorganized and...unprofessional. That in itself is scary! 
Title: Re: Sak Recall
Post by: slipkid on August 21, 2014, 05:45:05 PM
@ PrimeTime.

Bastards.

Here is my latest Davita story on this issue.  I have gotten statements from Medicare, and Davita is billing Medicare for the aluminum tests.  I am on a monthly basis filling a dispute with Medicare that the tests are required because of contaminated SAKs -- faulty medical equipment -- supplied by Davita.  I hope Medicare acknowledges the complaints and bounces the charges back to Davita.  A minor victory if Medicare does so in this sordid mess.
Title: Re: Sak Recall
Post by: PrimeTimer on August 21, 2014, 06:31:15 PM
My husband (the patient) just reminded me that Spectra Labs is a subsidiary of Fresenius. Maybe his center no longer test patients aluminum for fear of giving the appearance of a conflict of interest because of the SAK recall/aluminum issue. Maybe they would rather an outside lab do the testing but then why wouldn't they just come out and say that instead of putting us thru this little dance of theirs today? And even then, I wonder what would explain other Fresenius centers that ARE testing patients. We like using the NxStage cycler and we like using their Pureflow/Saks...but we also would like knowing what my husband's aluminum blood level is so that it can be regularly monitored for changes, like all other labwork. You'd think that since we are already saving the center time and money by doing hemo-dialysis at home and drawing the monthly labs ourselves at home, that they'd be willing to let us test his aluminum level at home as well or...that they would do it, like they told us they would.

 :rant; Needless to say, I am very ticked off right now but even more concerned than anything. Why would a center that has been so nice, easy to deal with and thorough suddenly become unorganized and not want to perform such an important lab test? It just does not make sense. There must be a part to this story that we are missing. Problem is, I don't give up that easy. I like to dig and seek out facts, especially when I feel something is amiss. That's a little harder to do these days, especially being the carepartner of an ESRD home-hemo patient. But, like I mentioned in my prior post, we are taking the Neph's prescription order for an aluminum blood level test to a lab approved by our insurance so at least we will not have to keep begging and/or bringing it up with his center.
Title: Re: Sak Recall
Post by: obsidianom on August 22, 2014, 04:41:36 AM
In the end, any blood test ordered by a physician for any reason that is medically necessary is covered by insurance. So if the idiot clinic wont do it, you can do it yourselves at the local hospital lab and and it should be ok. I order blood work all the time and its always covered for my patients as long as i have a diagnosis.
I dont think there is any conspiracy here as Fresenius has been good to us on all tests.

On the other hand I cranked at the Fresenius people recently as I wanted them to consider doing blood work for me persoanally as the care giver/dialyzer . They make money on me doing it and we pay higher electric bills and other expenses to do it at home. I just wanted them to do something for ME , not just my wife. They basically said tough Sh--T, we dont do anything for the care giver.  REAL NICE! 
Title: Re: Sak Recall
Post by: Simon Dog on August 22, 2014, 05:46:15 AM
On the other hand I cranked at the Fresenius people recently as I wanted them to consider doing blood work for me persoanally as the care giver/dialyzer . They make money on me doing it and we pay higher electric bills and other expenses to do it at home. I just wanted them to do something for ME , not just my wife. They basically said tough Sh--T, we dont do anything for the care giver.  REAL NICE!
The transplant clinic sent me 8 tubes to collect from a potential donor and ship back.   Fresenius was (by policy) unable to to the sample collection, even though it was directly related to the patient's treatment.
Title: Re: Sak Recall
Post by: iolaire on August 22, 2014, 06:21:05 AM
On the other hand I cranked at the Fresenius people recently as I wanted them to consider doing blood work for me persoanally as the care giver/dialyzer . They make money on me doing it and we pay higher electric bills and other expenses to do it at home. I just wanted them to do something for ME , not just my wife. They basically said tough Sh--T, we dont do anything for the care giver.  REAL NICE!
The transplant clinic sent me 8 tubes to collect from a potential donor and ship back.   Fresenius was (by policy) unable to to the sample collection, even though it was directly related to the patient's treatment.
My nephrologist's nurse (and nephrologist) could draw blood, prior to dialysis as a courtesy they drew my monthly blood for tissue matching (now quarterly).  Probably this is because they are also doing the vein work so they have to be certified for that type of thing.  Otherwise I found it hard to get the blood drawn, once in awhile I could get Quest labs to do it as part of another draw but no-one knew how to write an order to get blood drawn that I could take with me...  The hosptial's out patient lab would do it but they charged over $75 for drawing the bood - I have insurance but that just seemed outrageous and they were not close - another reference lab would do it for $35 but only took checks and didn't bill insurance...

So you might be able to ask your nephrologist if they could help if you both go in to the office for a real appointment.
Title: Re: Sak Recall
Post by: slipkid on August 22, 2014, 08:12:12 AM
Davita uses its own lab in Florida for blood tests.. We have to Fed Express our samples to them.
Title: Re: Sak Recall
Post by: Simon Dog on August 22, 2014, 11:08:30 AM
Davita uses its own lab in Florida for blood tests.. We have to Fed Express our samples to them.
Fresenius also uses it's own lab (Spectra).   I Fedex my samples to NJ, and I think there is another Fresenius/Specra lab on the west coast.

Quote
So you might be able to ask your nephrologist if they could help if you both go in to the office for a real appointment.
Went to the local hospital lab - the prospective donors insurance card worked wonders.
Title: Re: Sak Recall
Post by: Maggie and Jeff on August 22, 2014, 02:09:17 PM
After a full month using hanging bags only Maggie's Aluminum level has gone from 18 down to 13 :cheer:
We just sent in an AAMI to test the hanging bags.
Title: Re: Sak Recall
Post by: Hemodoc on August 22, 2014, 03:40:31 PM
Does anyone still have some of their PureFlow from right AFTER the recall? If so, please PM me please.

Thank you.
Title: Re: Sak Recall
Post by: Simon Dog on August 23, 2014, 09:34:40 AM
After a full month using hanging bags only Maggie's Aluminum level has gone from 18 down to 13 :cheer:
Still on Pureflow - went down from 13 to 10 after a couple of months.
Title: Re: Sak Recall
Post by: Hemodoc on August 23, 2014, 12:32:05 PM
After a full month using hanging bags only Maggie's Aluminum level has gone from 18 down to 13 :cheer:
Still on Pureflow - went down from 13 to 10 after a couple of months.

Do you have the routing papers to see if it is a SAK batch made by PiSA? Some folks are still reporting high levels and others are not. I wish NxStage was upfront in relating the continued risks, but they are hiding behind ill advised K/DOQI guidelines allowing up to 10 mcg/liter of aluminum in dialysate.  Fortunately for some, it appears that they are using PiSA for some of the SAKs as well.

Once again, getting some samples from the PureFlow of the completed batch for aluminum samples is something I have asked for and yet to get any responses.  What are folks fearing that won't send in this simple test? I don't get it.
Title: Re: Sak Recall
Post by: obsidianom on August 23, 2014, 12:44:08 PM
After a full month using hanging bags only Maggie's Aluminum level has gone from 18 down to 13 :cheer:
Still on Pureflow - went down from 13 to 10 after a couple of months.

Do you have the routing papers to see if it is a SAK batch made by PiSA? Some folks are still reporting high levels and others are not. I wish NxStage was upfront in relating the continued risks, but they are hiding behind ill advised K/DOQI guidelines allowing up to 10 mcg/liter of aluminum in dialysate.  Fortunately for some, it appears that they are using PiSA for some of the SAKs as well.

Once again, getting some samples from the PureFlow of the completed batch for aluminum samples is something I have asked for and yet to get any responses.  What are folks fearing that won't send in this simple test? I don't get it.
I should have our test results on aluminum and all other chemicals in the sak this coming week. We drew off a sample the other day. My clinic was willing to do it as my wife is still at 36 aluminum. That should give us some much needed info. I will post the results.
By the way, we did test the sodium and yes my wifes sodium did rise a bit from the sak being at 140. I relayed this to Nxstage. We will see what they are willing to do. 140 is just too high. It should be 137 or 138. That is what our clinic runs in center.
Title: Re: Sak Recall
Post by: Hemodoc on August 23, 2014, 02:49:57 PM
r. O, that is an incredibly important lab. It will be the first one yet reported on the current levels in the SAKs. The guidelines state that anyone with "aluminum overload" which I have seen defined in one paper as anything above a serum level of 30, should first be treated with aluminum free dialysate defined as <5 mcg/liter.

If your wife is still at a level of 36, then circumstantial evidence is that the levels are closer to 10 mcg/liter than to 5.

Thank you for getting this test done. It is time for NxStage to stop poisoning us.

Peter
Title: Re: Sak Recall
Post by: Maggie and Jeff on August 23, 2014, 07:18:18 PM
Saks are 304

hanging bags are 209


(http://jtpotteryusa.com/GL1200I/001%20001.jpg)

(http://jtpotteryusa.com/GL1200I/002%20001.jpg)

(http://jtpotteryusa.com/GL1200I/1%20001.jpg)

(http://jtpotteryusa.com/GL1200I/2%20001.jpg)

(http://jtpotteryusa.com/GL1200I/hanging%201%20001.jpg)

(http://jtpotteryusa.com/GL1200I/Hanging%202%20001.jpg)
Title: Re: Sak Recall
Post by: obsidianom on August 24, 2014, 06:02:10 AM
Well that report at lkeast indicates I was correct in not switching from the saks to the bags. It appears Nxstage has fixed the aluminum issue. I am awaiting our own results but assume they should be good too. We can all relax now. No more hanging bags for those who switched.
Title: Re: Sak Recall
Post by: Hemodoc on August 24, 2014, 11:31:42 AM
Well that report at lkeast indicates I was correct in not switching from the saks to the bags. It appears Nxstage has fixed the aluminum issue. I am awaiting our own results but assume they should be good too. We can all relax now. No more hanging bags for those who switched.

Not so fast Dr. O.

If they truly were at the level of 5 mcg/liter, why is your wife still at 36 and others over 50? Sorry to be cynical, but FMC OWNS Spectra. In addition, why are both 5 mcg/liter in this report? Why is it not 5.1 or 5.2 ect.?

My aluminum level went up on the SAKs. If it had been 11-13.5 and then down to 5, theoretically, the levels should have dropped dramatically but they didn't. If your report comes back at 5 and if I remember correctly you also are at a FMC unit, then that would be a bit strange as well.

According to the literature, if you are at a level of 5 or lower in the dialysate, the levels in the patient are quite negligible  Your wife's levels are still in a danger zone and accumulating throughout her body.

Sorry, but I am done with the PureFlow and going to stay with the bags.  The proof is in the pudding so to speak. Folks who have switched to the bags have higher Hb levels and lower Aluminum levels. Those on the PureFlow have higher aluminum levels and lower Hb. Sorry, but that speaks louder than some reported lab result from a lab owned by the largest dialysis provider in the world. something isn't adding up.
Title: Re: Sak Recall
Post by: Hemodoc on August 24, 2014, 12:04:37 PM
Lastly, if the levels truly are 5 mcg/liter, and I reiterate, if, then that proves my contention that there is NO safe level for aluminum period. K/DOQI and other sources define aluminum overload as a patient with serum levels higher than 30 mcg/liter. I would dispute that since I had significant symptoms and objective Hb drops with levels 14-17 mcg/liter. However, for sake of argument, I will give them the 30 mcg/liter level. In such a case, IF the levels are truly 5 mcg/liter, then Dr. O, your wife still has aluminum overload. And no, the PureFlow is STILL not safe.

I believe you should switch to bags immediately. A level of 36 is showing that she is still having aluminum deposits throughout her body that will take years to clear. Sorry, but I strongly disagree that we can just go back to the PureFlow.
Title: Re: Sak Recall
Post by: obsidianom on August 24, 2014, 12:48:10 PM
I simply dont buy the conspiracy theory. Fresenius and spectra have no reason to lie. Wy would they cover for nxstage? If anything Fresenius would rather have us on their system and not nxstage . If they could damage nxstage it would be good for their business.
WE have 7 other patients in or area on Nxstage and all but my wife have dropped back to under 10. They are using pureflow.
In the end I think my wife is an anomaly . She had the highest aluminum around here at 44 and is slowely dropping from 44 to 39  to 36 over the past 2 months. AS long as it continues to drop on pureflow we will stick with it. We check it monthly.
Now in my wifes case we could have an issue with our well water as it is very high in aluminum. It measured .238 with the norm under .01. So it is 23 plus times too high. We are now using a Britta filter for all drinking water. I hope it filters out aluminum as we cant seem to get an answer. It does filter out most metals. We just started this last month. Hopefully it should help.
If anyone knows more about the Britta system please let me know. It uses an activated carbon and ion exchange resin to filter water.  It does list copper, mercury and cadmium , chlorine and zinc  as being filtered. Since non renal patients arent harmed by aluminum it wouldnt list it anyway.

Title: Re: Sak Recall
Post by: Hemodoc on August 24, 2014, 01:59:25 PM
Actually, I didn't invoke any conspiracy theory at all. I simply stated as have several others that I don't trust the independent values of a lab completely owned by FMC. Nor do I trust the labs from DaVita for the same reason. Several have noted substantially different values on labs from these two entities and when they take them though their own medical groups such as with Kaiser.

In addition, the standard of care for anyone on dialysis with "aluminum overload" defined as over 30 in the serum is "Aluminum free" dialysate defined as <5mcg/liter. In this case, at 5 mcg/liter, they are not adhering to the guidelines since it is not aluminum free. In other words, if there is a measurable amount of aluminum they have not adhered to the guidelines.

Lastly, I am frankly surprised that your unit allows you to have the PureFlow in the first place with the well water results you have shown.

In any case, I am a month and half free of the PureFlow and my energy is starting to return, my Hb is back to normal for me values and the "brain fog" I have had for the last year is rapidly clearing as well. So, if you wish to continue the PureFlow that is up to you, but I would strongly counter that NxStage has "fixed the problem" or that you can go back safely to the PureFlow. Obviously, your wife is still aluminum overloaded at the level of 36 which statistically is not much different that 44 as far as lab variation goes.

When there is another alternative to NxStage, I will gladly say goodbye to them, they have broken the trust.
Title: Re: Sak Recall
Post by: Zach on August 24, 2014, 02:54:57 PM

We are now using a Britta filter for all drinking water. I hope it filters out aluminum as we cant seem to get an answer. It does filter out most metals. We just started this last month. Hopefully it should help.
If anyone knows more about the Britta system please let me know. It uses an activated carbon and ion exchange resin to filter water.  It does list copper, mercury and cadmium , chlorine and zinc  as being filtered. Since non renal patients aren't harmed by aluminum it wouldnt list it anyway.


Dear Dr. O,

I can't answer your aluminum question, but you should be aware of the issue with the BRITA filter adding potassium to the filtered water.

http://www.brita.net/ae/faqs_household.html?L=24

FAQs - frequently asked questions

I am on a potassium restricted diet, is filtered water still suitable for me?
BRITA cartridges contain potassium partly due to the production process and partly from naturally occurring potassium in the activated carbon.  This potassium is gradually released into the filtered water over several litres; the rate of release depends on the hardness of the water. The higher the hardness the faster the potassium is washed out.
 
Potassium is essential for many functions in the human body, especially for cell renewal.  As it is considered to be such a beneficial mineral, there is no maximum limit for potassium in the drinking water standards.  The amount of potassium in BRITA water is negligible and not relevant at all for people with normal health.
 
Individuals with kidney disease or those who have to monitor their potassium intake should be aware of the possible increase in potassium in the early litres of water filtered through each new BRITA cartridge and may wish to discuss this with their doctor. Contact BRITACare Customer Services for further information.

###

Please note:

I believe the above website & information is from the United Arab Emirates (UAE) BRITA website.

The American BRITA website FAQ is less forthcoming:
https://www.brita.com/using-your-brita/faqs/

 8)
Title: Re: Sak Recall
Post by: caregivertech1 on August 24, 2014, 03:14:00 PM
Interesting that Maggie and Jeff's Al was 5 micrograms/liter in both Saks and bags. On May 9th  (before we knew of the recall) I submitted a Sak AND a Pak sample to Spectra. We all know the Pak RO system is about the best there is. However both Sak and Pak had identical AL results of 8 micrograms/liter. How can that be? I really don't think Spectra has the sensitivity/accuracy to measure AL in water or Saks or bags.  We're testing blood serum AL every 2 weeks. Last result was 19, up from 12 2 weeks ago. Heard from a reliable source that all will be "resolved" by Oct. which to me means the current contaminated Sacs will all be exhausted from inventory. Now using 2 hanging bags to complete our 30L treatment. This is totally unbelievable.
Title: Re: Sak Recall
Post by: Hemodoc on August 24, 2014, 06:38:48 PM
Interesting that Maggie and Jeff's Al was 5 micrograms/liter in both Saks and bags. On May 9th  (before we knew of the recall) I submitted a Sak AND a Pak sample to Spectra. We all know the Pak RO system is about the best there is. However both Sak and Pak had identical AL results of 8 micrograms/liter. How can that be? I really don't think Spectra has the sensitivity/accuracy to measure AL in water or Saks or bags.  We're testing blood serum AL every 2 weeks. Last result was 19, up from 12 2 weeks ago. Heard from a reliable source that all will be "resolved" by Oct. which to me means the current contaminated Sacs will all be exhausted from inventory. Now using 2 hanging bags to complete our 30L treatment. This is totally unbelievable.

I agree, that doesn't sound right since the Bags to the best of my knowledge are produced by PiSA which was not involved in the recall. No Bags were recalled. Everyone with high levels of aluminum that switched back to the bags has had both symptom improvement and lowered Aluminum levels.

For anyone with aluminum overload, the guidelines state to have "aluminum free" dialysate. If the current PureFlow is truly only 5 mcg/liter, then indeed, that is still too high a level and the K/DOQI guidelines are complete baloney. For me, I am sticking with the bags until  a new machine is available.
Title: Re: Sak Recall
Post by: Maggie and Jeff on August 24, 2014, 10:04:35 PM
I posted 2 separate SAK lot # tests Both showed .005

I posted 1 Hanging bag test it showed Less Than (Or as I was corrected earlier)<.005

I figure less than <.005 is as low as the lab can test.  So the first reading on the lab instrument would be .005 maybe even if there was .003 it would still show .005.

I saw that the SAK's had elevated:
Aluminum @ .005 & .005
Chromium @ .006 & .007
Copper     @ .007
Zinc         @ .005
sulfate      @ 1.4   & 1.3

The hanging bags had this elevated:
Zinc .045

We have a AAMI out to the lab on our hanging bags so I'll have those results soon.

Maggie is feeling better and sharper mentally after a month of using bags.  Maggie's AL was 18 last month and that was up from the previous month.  The Doc. wanted to know "Where is the aluminum coming from?  Your dishes?"  We both said it's the dialsate but we could use the hanging bags and here are the results from the AAMI's of both.

So we are using the bags and now the AL is 13.

I'd switch to bags for a month and see if the AL comes down even faster.
Title: Re: Sak Recall
Post by: obsidianom on August 25, 2014, 09:03:36 AM

We are now using a Britta filter for all drinking water. I hope it filters out aluminum as we cant seem to get an answer. It does filter out most metals. We just started this last month. Hopefully it should help.
If anyone knows more about the Britta system please let me know. It uses an activated carbon and ion exchange resin to filter water.  It does list copper, mercury and cadmium , chlorine and zinc  as being filtered. Since non renal patients aren't harmed by aluminum it wouldnt list it anyway.


Dear Dr. O,

I can't answer your aluminum question, but you should be aware of the issue with the BRITA filter adding potassium to the filtered water.

http://www.brita.net/ae/faqs_household.html?L=24

FAQs - frequently asked questions

I am on a potassium restricted diet, is filtered water still suitable for me?
BRITA cartridges contain potassium partly due to the production process and partly from naturally occurring potassium in the activated carbon.  This potassium is gradually released into the filtered water over several litres; the rate of release depends on the hardness of the water. The higher the hardness the faster the potassium is washed out.
 
Potassium is essential for many functions in the human body, especially for cell renewal.  As it is considered to be such a beneficial mineral, there is no maximum limit for potassium in the drinking water standards.  The amount of potassium in BRITA water is negligible and not relevant at all for people with normal health.
 
Individuals with kidney disease or those who have to monitor their potassium intake should be aware of the possible increase in potassium in the early litres of water filtered through each new BRITA cartridge and may wish to discuss this with their doctor. Contact BRITACare Customer Services for further information.

###

Please note:

I believe the above website & information is from the United Arab Emirates (UAE) BRITA website.

The American BRITA website FAQ is less forthcoming:
https://www.brita.com/using-your-brita/faqs/

 8)
Thanks for that Zach. You are right about the potassium . I noticed my wifes potassium go up from 4.9 to 5.1 since the start of the Britta. In her case its ok as she gets low after dialysis anyway (3.7) , so it actually may help. I wish I knew whether it takes out aluminum.
Title: Re: Sak Recall
Post by: Zach on August 25, 2014, 05:04:50 PM

 I wish I knew whether it takes out aluminum.


Dear Dr. O,

Here are the results on several brands of countertop water filters.
I'm not sure how reliable the web site sponsor is, so take it as you will.

http://www.naturalnews.com/046536_water_filters_heavy_metals_lab_results.html

According to their labs, the BRITA filter adds aluminum.

Note:  One needs to provide an eMail address to read the results, so I added a screen shot below.
 8)
Title: Re: Sak Recall
Post by: obsidianom on August 26, 2014, 05:05:42 AM

 I wish I knew whether it takes out aluminum.


Dear Dr. O,

Here are the results on several brands of countertop water filters.
I'm not sure how reliable the web site sponsor is, so take it as you will.

http://www.naturalnews.com/046536_water_filters_heavy_metals_lab_results.html

According to their labs, the BRITA filter adds aluminum.

Note:  One needs to provide an eMail address to read the results, so I added a screen shot below.
 8)
Zach, you are a SAVIOR. I cant thank you enough.
I am apalled at the poor performance on the Britta. My wife actually has been feeling poorly the past 3 weeks since we started using it so perhaps that is the cause as our water is already high in aluminum and Brtitta makes it worse.
I advise everyone here on dialysis to read the lab reports on these water systems.
I just dumped the Britta and ordered Zero Water system. That has 100 % aluminum reduction. It has an ion exchange system as its primary filter rather then charcoal like Britta. Charcoal does nothing for aluminum or other metals. 
This is why this is such a great site . We all pitch in to help each other. Thanks again Zach.
Title: Re: Sak Recall
Post by: Maggie and Jeff on August 26, 2014, 08:12:42 PM
Our clinic nurse says 13 on Maggies AL is the lowest it has been since January 2014.

The labs where pulled 6 weeks after starting hanging bags only.

I'm hoping that she will be under 10 when we pull labs next time.
Title: Re: Sak Recall
Post by: Hemodoc on August 26, 2014, 09:09:49 PM
Mine also dropped to 13 last month. Will see what the next one does. But clinically, I feel significantly improved. I am not going back to the PureFlow. It is time for NxStage to eliminate all aluminum from their products.
Title: Re: Sak Recall
Post by: caregivertech1 on September 05, 2014, 02:31:32 PM
Maybe my math is crazy but I just read the recall letter again and noticed the FULLY DILUTED affected Saks averaged 12.2 mg/L. They also say the product specification requires CONCENTRATE aluminum levels to be less than 10 mg/L. Are they referring to the FULLY DILUTED Saks or the CONCENTRATED BEFORE DILUTION Saks? If the latter that would put the AL concentrated Sak limit at 210 mg/L for Sak 302 which is diluted by 21. Surely they are talking in both cases about diluted Saks. Or are they?