Low BP on NxStage - ideas?

[cattlekid]

So my BP has been dropping lately on my NxStage treatments.  I come in at around 120/80, then as soon as I am on the machine, it drops to 110/70.  It continues to drop throughout the treatments.  Last night I tried just turning off the UF so that I could finish all of my treatment and it went down to 80/60.  Needless to say, it was rough cleaning up the machine afterwards, had to stop every five seconds to sit down.  Ugh.

I've already increased my dry weight a half a kilo and I don't take my BP med (metropolol for controlling pulse due to anemia) until after my treatment is over.  So I'm coming in with no BP med in my system.  I only give myself 100cc of saline if my BP drops below 100 systolic and after that, I usually just terminated treatment if it didn't stay up over 100.  But then I realize that I'm starting to cut most of my treatments by 10-15 minutes, and I don't want to do that long term. 

Any other possible ideas?  I hate to keep increasing my dry weight because I am afraid that I may end up with fluid around my heart.  Even though I never have any edema and I don't feel winded at any time.  But I will jack it up another half a kilo if that is the only possible idea.

Thanks!!

[Lovebelle]

Does your doctor have any suggestions for you? When this happens to me I give myself more Saline, usually up to 300cc. My Nurse also said that the Nx Stage machine tends to take an additional 300-400cc of fluid (on top of the UF), so maybe you are challenging your body a bit too much. I would definitely mention it to either your home nurse or nephrologist to see what they suggest. Good Luck!

[Gerald Lively]

Cattlekid:

I am not a doctor, but I played one when I was young and in my teens.

Please consider this suggestion:  Do you own dry weight calculation.  What you described happened to me.  Upon standing immediately following a dialysis session, my blood pressure would drop to something like 85 over 50.  I suspected that they took too much water out, twice it was six kilos.

To determine your dry weight, weigh first thing in the morning every day.  You should know how you feel; holding water, constipated, over-eating, etc. Try for that day when you feel light.  Hit that number twice or close to twice.  After a few days or a week, you should have an idea of your lowest average weight.  Not your lowest all-time weight, your lowest average weight.  That is your dry weight for now.  Use that even if it means removing only one kilo of water.  If you feel like you need to take more out, lower the out-take one kilos per session.

You shouldn’t feel bad after dialysis.  Be honest with yourself; if you are getting fat, change your dry weight upward.  This worked very well for me when I started taking diuretics.  My calculations  were made before every session and adjusted.  Diuretics steadied my weight magnificently.

Even after I had this all figured out, my BP fluctuated but it was well within an acceptable range.  Weigh everyday first thing in the morning, no clothes on.  I won’t look.

Manage your own healthcare.  Talk to me if you need to hear from me.  I am not here everyday, so use the private mail system here.  Or send it to:  glively@livelyroots.com

I am halfway through my radiation protocol for Lymphoma, six more zapping sessions.

Gerald Lively 

[amanda100wilson]

Cattlekid, do you take the prime and rinseback fluid into consideration when setting your  UF, not the  volume but the rate?  I was taught to add 300mls to the volume, then divide by the number of hours I want to remove fluid in.  Don't be afraid to give more saline.  I give what I need to bring the systolic above  100.   If it remains low, then I would then take the UF to zero and up the rate of dialysate so that the light at the side of this display goes off and the FF is restored to the setting that you usually have.  This way, your blood is still being cleaned.  When the treatment ends, thereisno reason why you can't give yourself some saline if your BP is still low, and you can also just sit and wait a  while before rinsing back to allow your BP to come up a bit, which hopefully it will do if you have also given some more saline.  Just leave the pump running to keep the blood moving. I can't promise that it will work but it may help.  Do remember, your dry weight may have increased because of an improved appetite and you may also have built some muscle mass.  I understand as I seem to be getting into the same problem.

[cattlekid]

Amanda and Gerald, thanks for your replies. 

Gerald - I think you are right, I'm just getting fat LOL  I have increased my dry weight another .2 kilo for a total increase of almost one kilo.  The funny thing is that I do weigh myself every morning like you suggested.  I am always at least a kilo down from the weight I ended my previous night's session at.  So for example, last night I ended my session at 96.2 and this morning, here I am at 95.3.  I used to use 95.5 as my dry weight and found that my BP was just getting way too low and I had to give myself saline all of the time. 

Now, I've taken my dry weight all the way up to 96.4 and last night, I still ended my session with a standing BP of 85/50.  This is getting frustrating.  I am going to talk to the dr. today about switching or completely removing my last BP med to see if that will help the situation.

Amanda - I'm not sure I understand what you are talking about.  I was taught to take my weight, subtract out my dry weight and then set the machine rate for half of that, and the volume for the full amount - not adding or subtracting any more for prime/rinseback.  So for example, since I run 2 hours 15 minutes, last night I needed to take off 1.1 kilos - so I set the rate for .55 and the volume for 1.1.  Should I be doing something differently?  When I weigh myself after my treatment, I always hit my goal and don't see any additional fluid removed.

[boswife]

What BFR are you running?  If you dont mind going a bit longer, you may lower your BFR and then you can slow down your UFR as well.  Mabie a slower take off would be easier on your heart.  I know longer slower is always talked about as easier on the heart, so mabie lengthining your treatment time would help.  Works for hubby     It kinda sucks to sit longer but if it works, it's worth it....  Are you doing heperin?  Bo is not and we run at 300 if he has  2.o to take off, but if he's been good and only has 1 or so, we will run a bit faster up to 350 or so to get done a bit faster.  uhhh,, gotta run but will be checkein back ..

[cattlekid]

Boswife, I'm sure I'll get raked over the coals for this but I do 450.  I work full time and can only squeeze in 2-2.5 hours at night between work, dinner and the need to get to bed at a reasonable hour. I am only 41 and have no heart issues so I'm going to stick with that for now.  I can't add any more time on without impacting my ability to continue to work full time.

[big777bill]

 I had the same problem not too long ago. We had to raise my dry weight by 2 kilos. We did this a half kilo a day until my BP came up to at least 100. It had dropped as low as 80/43. I'm 6ft 3in. and weigh 120 kilos so you can imagine how I felt with BP that low. We also had to take bolus of as much as 300 a day until I got over this.

[amanda100wilson]

I was definately told to add .3 kg to the volume, then divide by the time.  You are ha
Vying it because you are calculating to take it off in two hours.  I divide it by the number of hours I want to run for which is usually themax. Number of hours that I can afford to run in the time that I have available.  I believe in running longer and slower although there has to be a compromise since it take a big chunk out of the day regardless. 

Do other people add something to the volume to account for rinseback?  I am curious to know?

[cattlekid]

Just got off the phone with the nephrologist.  We are going to cut my metropolol in half to 12.5 mg and see if that helps.  If not, he is going to add proametine (sp?) that is a vasoconstrictor that will help keep the BP up at a reasonable level during treatment. 

[boswife]

haha,, no coal raking ............ we all do what's best for 'us' and thats as it should be.  It was just a thought 

[Bill Peckham]

Have you determined if you are too dry? There are a couple easy tests.

The easiest is the pinch test looking for poor skin turgor -- the skin being not as elastic as normal. Pinch the skin together in the back of the hand when you let go does it go right back into place or does it take a while to get back normal? If it is taking a while it is a pretty clear indication that you are too dry.

Another test is to lie down and observe the neck veins. You should be able to see a pulse in the neck veins when you are lying down - if it isn't there you may be too  dry. (BTW if you can still see a pulse when you are standing you may be too wet).

It is a good idea to do these test periodically so you know what is your normal.

[stringbandbeth]

 My hubby has always battled low BP'S on Hemo...after 2 years and many doctors and tests they never really confirmed the cause. The docs and RN's said it's just how some folks react to dialysis. He started taking midodrine before and once during his treatments and vastly improved. We used to struggle to keep him above 90/50 and stuff like 80/40 was not unusual . It's fast acting but short lived...about 60-90 min so sometimes he has to take a second dose. It has prevented us from cutting treatments short or adding back all the fluid we just took off and his #'s are great right now.

[Zog]

My wife usually runs a low blood pressure 100's/50's (for the past 4 years) and sometimes as low as 80's/40's and she has just lost part of her vision in her right eye, so they are hopefully going to address her chronic hypotension which may have caused her loss of vision (due to ischemic optic neuropathy).  Cattlekid, I don't think you are anywhere near this level of danger, but they are many reasons to want a normal blood pressure.  She has raised her dry weight but it doesn't seem to be having much of an effect.

I totally understand trying to keep the treatment time down.  It is no fun doing dialysis past midnight and then trying to go to work the next day, and we've been there and done that several times.

[cattlekid]

I should give a bit of an update.....I had almost totally discontinued the metoprol and upped my dry weight by about .4  kilos and that seemed to solve most of the problems.   However, I had a minor heart attack on this past Friday afternoon and right away the cardiologist increased my metoprol dosage to 100 mg.  So now I'm back to square one.  Now that I am out of the hospital, I am going to see him today for my followup.  I plan on asking him if I can decrease the metoprol dosage or as some have suggested here, take a dose of miodrine before treatments to up the BP just to get through. 

[Zog]

I'm sorry to hear about your minor heartattack, Cattlekid.  What happened?  Is it in another post?

I would be wary of the drug induced feedback loop you could have taking your bp up with one med and down with another.  That system could spiral out of control.  Sometimes it seems that without functioning kidneys all they can do is treat the symptoms.  There is no cure for the disease.

[amanda100wilson]

Definately try giving a saline bolus.  That often pulls mine up and then I still achieve my UF goal (minus the bolus)