Dr. Agar's Concept Again Proven Correct in First Stage Test

[obsidianom]

Those of you who have read Dr. Agar's writings or my posts about them have seen that there are 3 main points he makes that are key to quality dialysis.
1. Time on machine. A minimum of 10% total time or at least 16.8 hours per week. (17)
2. UF rate at less then 10ml /kg / hour  (best at 5 ml/kg/hour)
3. Blood speed at 350 or less
 
Now as a doctor I realize that 1 patient proves nothing. However 1 patient combined with hundreds or more of Dr. Agars patients can be a good bet.
I decided to experiment with my wife to see if Dr. Agars theories work for her.
Backround: we have done 5 days per week on Nxstage for almost 2 years. In the past it was around 15.5 hours per week. Not too bad but not the magic number of 17.   Doing this she did well compared to in center but there was one issue. On the day after her day off dialysis she woke up each time feeling poorly and uremic. The morning until dialysis was hard on her.      Example: Dialysis Sunday, then off Monday. Tuesday morning feeling sick until dialysis in afternoon. This has gone on for almost 2 years despite moving Sunday dialysis to after noon .
Last week and this week we increased dialysis time to 3.5 hours per treatment giving us 17.5 hours total. We kept same volume of dialysate (30 liters) and same blood speed, 340. The UF (only a small amount) was set at .3 per hour which is well under Dr. Agars upper limit. (same as before) . So the ONLY change was adding about 20 -25  minutes per treatment. ( we had been at about 3 hours 5 to 10 minutes before).

Results : phase 1.  This test was done subjectively by her and me and another doctor who checked her and has seen her on the same day weekly for years.
The results were amazing. Normally she had difficulty walking and focusing and felt ill. The 2 days now we tested she was walking on her own with no support, walking steadily, bouncy energetic gait, clear head, no feelings of illness AT ALL. It was like seeing someone go from a sick bed with the flu back to normal. She felt it, I saw it and the other doctor noticed it immediatly .,''What did you do" ? he asked before we told him what we did. He was amazed.  She actually went on her treadmill to walk 26 minutes BEFORE dialysis both times , which she could NEVER do before.
  Phase 2 . will be objective. Next week we will do blood work. I realize the blood work has limited use as it tests urea and area reduction and of course electrolytes and phosphorus etc. 

Botton line, we clinically improved her greatly by only adding a few minutes time to each treatment without changing anything else . We simply followed Dr. Agars tenets and crossed the "magic" 10% of time line . Its nice to see in this case at least Dr. Agar has been proven correct in our phase 1 results. I will report phase 2 in 2 weeks.

For those on Nxstage it does bring up the question of whether volume alone is really the important value as Nxstage claims. We didnt change the volume of 30 liters, only the time on machine by slowing down the speed of the dialysate.  I beleive t is both time and volume that are critical. I cant prove it but that is my sense. You need enough time to clear many of the middle molecules that are protein bound. Kind of like a washing machine needs anough minutes of agitation to clean clothes. More volume of dialysate without enough time on machine may not be enough. We had already increased the volume for my wife from 20 to 30 liters back around 6 monthe ago and it helped overall but did not change her day off issues. Only time did that.
Hemodoc perhaps you can weigh in here. Do you think we focus too much on volume and not enough on TIME with Nxstage?  Perhaps SHORT daily is too short? Could there be a minimum time per treatment also? (like 3.5 hours?)  Should we be pushing 17 hours weekly for all Nxstage patients? (and everyone else too if possible?) 
In Australia they certainly do this, and their staistics are much better than the US.

[jeannea]

I only spent 6 months on hemo before switching to PD so I have limited experience. I was doing 3.5 hrs 3 days a week. I'm very short and didn't weigh much after being seriously ill. Doing 17 hours a week at home may be bearable. I think doing 17 hrs a week in center I may have lost my mind. I don't like spending that much time with people I don't know without privacy or comfort. It makes me cringe thinking about it. I don't know if it was enough dialysis for me or not. I had a little kidney function left from my failed transplant. My numbers were good. I had a lot of other medical problems so it's hard to know if when I felt bad it was a lack of dialysis or other stuff. That is my subjective experience.

On the other hand, as a scientist, I think you are probably right. Longer dialysis can really make a difference in quality of life. It's a shame we can't provide that to more people. Someone could probably spend years studying which molecules are cleared better with longer dialysis. But does that detail matter to the patient? Not if they feel better. I do wonder how many patients would be willing to spend more time in center. (Regardless of the population here on this board, there are many patients unable to do home hemo.)

[Hemodoc]

As much of a fan of Dr. Agar as I am, they are not "his" theories. Dr. Scribner and his colleagues including Dr. Chris Blagg and Dr. Carl Kjellstrand dialyzed their patients in the 1960's up to 24 hours per week with thrice weekly 6-8 hour nocturnal at home sessions. Ultra-short dialysis came into being after the 1973 ESRD program.

Carl Kjellstrand published his "Un-physiology" theory of dialysis in I believe 1974, but I would have to look it up again to clarify the exact date. His theory has been castigated and ignored by American dialysis and American nephrology ever since because its application would have reduced their profits. Nocturnal daily hemodialysis started in Canada in the 1990's as a strategy for patients who did not tolerate UF. The 10 ml/min/kg comes from another researcher.

Japan has used these strategies even in their in-center patients for decades. Tassin France has used the old Scribner thrice weekly 6-8 hour treatments without stop since learning of them in Seattle during the 1960's.

So, once again, Dr. Agar is a wonderful researcher in his own right, but longer, more frequent, gentler dialysis preceded Dr. Agar, but he did learn as the Americans did not. Dr. Agar has had the personal mission over the last decade or more to educate American nephrology, but to date, America is more concerned about greed than patient outcomes.

The NxStage is very low on dialysate volume and operates on the solute kinetics curve in the early phase before it plateaus which means it never reaches the most efficient use of TIME because the dialysis volume is so low. All other systems operate in the plateau of that curve thus giving NxStage it's Achille's Heal, volume. With 60 liter treatments, it operates at the beginning of the plateau of the solute curve but I cannot tolerate that kind of sodium load. NxStage still has not arrived as an optimal machine. If they adjust their sodium to the 135-136 mmol range, then combined with their ultra-pure dialysate, NxStage at that point will be quite competitive even with new machines that will soon come to the market place.

[obsidianom]

I only spent 6 months on hemo before switching to PD so I have limited experience. I was doing 3.5 hrs 3 days a week. I'm very short and didn't weigh much after being seriously ill. Doing 17 hours a week at home may be bearable. I think doing 17 hrs a week in center I may have lost my mind. I don't like spending that much time with people I don't know without privacy or comfort. It makes me cringe thinking about it. I don't know if it was enough dialysis for me or not. I had a little kidney function left from my failed transplant. My numbers were good. I had a lot of other medical problems so it's hard to know if when I felt bad it was a lack of dialysis or other stuff. That is my subjective experience.

On the other hand, as a scientist, I think you are probably right. Longer dialysis can really make a difference in quality of life. It's a shame we can't provide that to more people. Someone could probably spend years studying which molecules are cleared better with longer dialysis. But does that detail matter to the patient? Not if they feel better. I do wonder how many patients would be willing to spend more time in center. (Regardless of the population here on this board, there are many patients unable to do home hemo.)

Thats where nocturnal in center or extended hours comes in. I agree it is not fun and its a trade off. As a doctor i always give my patients the best advise i can and then we discuss alternatives if they cant do the best ,as its ultimatly their choice and what they are willing to do for their health. Everone has to decide for themselves what they value and at what cost , be it time or money. I can only provide information and help with logistics.
I do know that our short hours on dialysis in this country leaves us with very poor results for our patients compared to countries where they do more time on machine. I wish I could fix that.

[obsidianom]

As much of a fan of Dr. Agar as I am, they are not "his" theories. Dr. Scribner and his colleagues including Dr. Chris Blagg and Dr. Carl Kjellstrand dialyzed their patients in the 1960's up to 24 hours per week with thrice weekly 6-8 hour nocturnal at home sessions. Ultra-short dialysis came into being after the 1973 ESRD program.

Carl Kjellstrand published his "Un-physiology" theory of dialysis in I believe 1974, but I would have to look it up again to clarify the exact date. His theory has been castigated and ignored by American dialysis and American nephrology ever since because its application would have reduced their profits. Nocturnal daily hemodialysis started in Canada in the 1990's as a strategy for patients who did not tolerate UF. The 10 ml/min/kg comes from another researcher.

Japan has used these strategies even in their in-center patients for decades. Tassin France has used the old Scribner thrice weekly 6-8 hour treatments without stop since learning of them in Seattle during the 1960's.

So, once again, Dr. Agar is a wonderful researcher in his own right, but longer, more frequent, gentler dialysis preceded Dr. Agar, but he did learn as the Americans did not. Dr. Agar has had the personal mission over the last decade or more to educate American nephrology, but to date, America is more concerned about greed than patient outcomes.

The NxStage is very low on dialysate volume and operates on the solute kinetics curve in the early phase before it plateaus which means it never reaches the most efficient use of TIME because the dialysis volume is so low. All other systems operate in the plateau of that curve thus giving NxStage it's Achille's Heal, volume. With 60 liter treatments, it operates at the beginning of the plateau of the solute curve but I cannot tolerate that kind of sodium load. NxStage still has not arrived as an optimal machine. If they adjust their sodium to the 135-136 mmol range, then combined with their ultra-pure dialysate, NxStage at that point will be quite competitive even with new machines that will soon come to the market place.

Thank you for the backround history. Dr. Agar is like the modern day messanger for the earlier doctors. (like Moses with the 10 comandments ). He has done a wonderful job explaining and bringing forth the message even if it is ignored by many in the US. I love reading his blogs and writings.
I have come to agree on the sodium. After researching this a lot it appears the majority of findings show lower sodium is beneficial to most patients. I am going to push Nxstage (it probably wont do much good but I will try) to lower it even if it is a compromise to 137.5 or so, or 1 sak type at 135. I think it would help lower BP in many patients too.