BFS and Dialysate

[tyefly]

I talk to my clinic today about increasing my dialysate from 20 L to 30 L.... after a long conservation and letting them think about it....they called and said OK.....  but  they said that I would have to increase my BFS  from 350 to 450 and maybe 500.....  I was shocked..... while I was training they wanted me to run at 400  while when I was in center I was running 350 and have never ran faster than that..... try to keep the pressure at 200 or less...   they told me that my pressures can go as high as 300 but 250 was good.....  Everything I have read here and else where and everyone I have talk to about learning everything I can about Dialsysis said to keep the pressures at 200or less and dont run fast ....protect the fistula.....  I told the clinic that I was concern about running that fast.....they said   if you cant do the speeds than maybe you wont be able to run the 30 L..... I was shocked....why do they want me to run at those speeds.....

[Zog]

Why do you want to go from 20L to 30L?  Is it something in your labs?  If you run a pressure over 200 the blood in the line will actually not pump at the speed the pump is running at.  The pump will only spin faster, but the blood isn't going to move much faster.  Your vascular surgeon should be the authority on how fast your fistula can run.

There are 4 things that affect your treatment time.

More UF (longer)
More Dialysate (longer)
Higher Blood Flow Rate (shorter)
Higher Filtration Fraction (shorter)

If you are shooting for a particular time, there are simple formulas they can use to play with those 4 variables until they get the time right. 

[Zach]

Here's an interesting blog written by Hemodoc.  It's entitled, "Taking NxStage System One to the Max"

http://www.billpeckham.com/from_the_sharp_end_of_the/2010/02/taking-nxstage-system-one-to-the-max.html

[Zog]

Most NxStage recommendations, design, concept, ulterior motives are geared to save dialysate so they could make the pureflow machine work in home and bagged dialysate travel an option.  The filtration fraction of say a Gambro Phoenix machine is a whole lot more than a NxStage.  Most in-center docs get a little snobby when they speak of their mighty in-center machines and their superior urea sucking capabilities.  I have always wondered if the filtration factor could be variable during treatment to shake out different sized molecules.  This is probably a silly thought, but I don't have a research lab.  The bigger in-center machines have all kinds of modeling and monitoring sensors and techniques that you have to perform manually on the NxStage.  Picking a NxStage treatment is a lot of trial and error using labs, but it is worth it.

Here's a spreadsheet I made with the treatment time calculation I came up with:

http://spreadsheets.google.com/ccc?key=0AiEa8NMba3u9dFF5WnhjQ3J3OGo1OGxtMDAyemZYVXc&hl=en

You will have to download your own copy to play with.  I haven't figured out how to make this interactive without leaving it where someone could mess it up.  I can't remember if I put a logic check in it for positive values or UF time without dialysate.  It doesn't have the real world time either that accounts for every time the dialysate pump shuts off for checks (yellow 2, 7, .

[Malibu]

Interesting.  Thanks for posting the link Zach. 

Tyefly, what is the motivation behind you wanting to increase your dialysate?

[Zach]

Interesting.  Thanks for posting the link Zach. 

 

[tyefly]

Basically   longer time  and more ability to take out toxins.....  The concept more is better is my approach....  And like Peter,s  paper on DSEN.... I am want to try to max out my perscription for the best results.... Nocturnal will be my next goal.....   Plus my labs at 20L were not as good as they should be.....  lower than in center for sure.... I had a higher BUN both pre and post and I just didnt feel as well as I did when in center.... So I think more will be better......  I have already done 2 days at 30L and today I feel much better.... I will run a couple of weeks and do labs and we will see how my labs look.....

[Zog]

How much time are you doing and at what blood flow rate?  That number of blood liters processed number at the end of treatment tells a whole lot more about your treatment than time or amount of dialysate.

If someone tells you to up your blood flow rate as a result of raising your dialysate they are just trying to keep you on the same amount of time each day.

We got near close to normal numbers on all lab values by doing 25L at 25% filtration fraction when Jenn was pregnant.  We didn't even care about kt/V because Jenn's pre-BUN was already NORMAL.  We were running 4 hours at 500 ml BFR then too with baby monitors on.  It was a wild ride 7 days a week. 28 hours/week of dialysis at 500 ml/min BFR.  I think we processed about 800 L/week of blood.

Sometimes I wish we were back on that schedule for Jenn's lab's sake, but it took a lot out of us being on from 7:30 PM to 11:30 PM to 12 PM everyday.  It is easier to just take your binders and watch your diet in some cases.

Weight and diet are the other factors affecting your treatment time per given lab result.

[tyefly]

I am doing BFS 400 and FF 33   for 4 hours....  blood processed is 98L ....  6 days a week....   
   I hope my labs will be good...  and most important that I feel really good.....  its alot of time increase to do this Nxstage....   IN center I was doing 9 hours a week..... now I am doing 24.....  But the freedom of travel is worth the effort.....

[rocker]

One thing no one has mentioned wrt NxStage and time is clotting.

In-center dialysis machines have a means to deliver Heparin continuously throughout treatment.  NxStage has no such ability, most home dialyzers rely on a large dose of Heparin at the beginning of the treatment (Heparin dialyzes out).

This is why NxStage cannot be used as a nocturnal machine by most people.

I know that when hubby's hemoglobin got high enough (over 12), he began clotting filters.  We avoid this now by giving 50ml saline every hour - obviously not an option during nocturnal, and probably doesn't work for that long anyway.

Anyway, if they wanted you to increase blood flow to keep the treatment time roughly the same, avoiding clotting may be the reason.

 - rocker

[silverhead]

Rocker, I have to disagree about this:

Quote: In-center dialysis machines have a means to deliver Heparin continuously throughout treatment.  NxStage has no such ability, most home dialyzers rely on a large dose of Heparin at the beginning of the treatment (Heparin dialyzes out).

This is why NxStage cannot be used as a nocturnal machine by most people.   end quote

those who are doing Nocturnal with the NxStage do so with a different cartridge, which has a provision for using a Heparin pump, supplied by their Center to accommodate that feature.  And they don't refer to it as Nocturnal, but instead as "Extended" .......

[rocker]

Rocker, I have to disagree about this:

Quote: In-center dialysis machines have a means to deliver Heparin continuously throughout treatment.  NxStage has no such ability, most home dialyzers rely on a large dose of Heparin at the beginning of the treatment (Heparin dialyzes out).

This is why NxStage cannot be used as a nocturnal machine by most people.   end quote

those who are doing Nocturnal with the NxStage do so with a different cartridge, which has a provision for using a Heparin pump, supplied by their Center to accommodate that feature.  And they don't refer to it as Nocturnal, but instead as "Extended" .......

Interesting.  I have been told several times by my center that there is absolutely no way to infuse Heparin during treatment with NxStage, and hence absolutely no chance of extending treatment.

Do you have a reference on this that I can take to my center?  I would really like for my husband to try nocturnal if possible.  (He always slept through treatment in-center....so much so that on nights he couldn't sleep, he'd turn to me and say "Make noises like a dialysis machine.")

 - rocker

[Harvey Wells]

Most if not all of the nocturnal NxStage users are at independent centers with one exception - RAI.  Most corporate structures are to concerned with liability exposure and are waiting for several nocturnal studies to be evaluated and published.  On the short, if you're in a corporate center you may have to wait unless you're near an independent or RAI facility.  Regardless of center your Nephrologist will have to be on board and in most cases unless the center approves and has a nocturnal policy they won't approve.  NxStage nocturnal can and is being used nocturnally by NKC (Northwest Kidney - Seattle), Wellbound Dialysis, Reuben in NYC and several RAI's as well as others with probably several hunderd dialyzors and there is a heparin pump. 

[Zog]

If you have lots of money laying around  you can buy a crit-line monitor and NxStage OneView touch screen interface to go along with your IV pole heparin pump and NxStage System One.

[Bill Peckham]

Rocker, I have to disagree about this:

Quote: In-center dialysis machines have a means to deliver Heparin continuously throughout treatment.  NxStage has no such ability, most home dialyzers rely on a large dose of Heparin at the beginning of the treatment (Heparin dialyzes out).

This is why NxStage cannot be used as a nocturnal machine by most people.   end quote

those who are doing Nocturnal with the NxStage do so with a different cartridge, which has a provision for using a Heparin pump, supplied by their Center to accommodate that feature.  And they don't refer to it as Nocturnal, but instead as "Extended" .......

Interesting.  I have been told several times by my center that there is absolutely no way to infuse Heparin during treatment with NxStage, and hence absolutely no chance of extending treatment.

Do you have a reference on this that I can take to my center?  I would really like for my husband to try nocturnal if possible.  (He always slept through treatment in-center....so much so that on nights he couldn't sleep, he'd turn to me and say "Make noises like a dialysis machine.")

 - rocker

The cartridges are called 171B - I've been doing extended overnight dialysis with the System One since January 2008, using a separate heparin pump. It's by far the least burdensome form of dialysis that I've tried. As I said in my comment on expanding the bundle - "frequent, overnight dialysis reduces the CKD5 burden to its irreducible core."