NxStage Gaining Ground On Growing Adoption Of Home Hemodialysis

[obsidianom]

You could easily run 50 liters on the slower system at 12 liters per hour for 4 hours, 10 minutes.

Great info - thanks again.

This would put my treatments on par with what I do now with the BabyK, though I only do 4 days a week with that systems (Tues/Thurs/Sun 4 hours and Friday for 3 hours),  so it appears that for me the option would be "daily" rather than "short daily".    Given that, I wonder if there would be a benefit to NxStage 5 or 6 days a week as opposed to increasing the BabyK frequency.  They don't make figuring this out easy.

But, the real issue is getting onto nocturnal with a slower blood flow.

The big advantage of adding days by going to 5 or 6 is less UF required per treatment and less water build up between treatments.
John Agar writes that safe speed UFF is below weight times 5ml/hour.  So if you weigh 100 kg , the safest speed would be max. 500 ml /hour or .5 liters per hour.  Above that speed begins to stun the heart and avove 10ml/hour times weight which in this case would be 1 liter per hour, CAN BE DEADLY.  So if you have less water to take off per session it is easier to stay at a slower safer number.  Personally I would go as slow as possible to reduce all the negative issues with faster speeds like cramps and headaches etc.   
Obviously nocturnal would allow slower UF by its very nature anyway.
If you do daytime, Nxstage gives you more time on machine then your current time of 15 hours. You would get at least 21 hours at 5 days and 25 hours at 6  days which approaches nocturnal levels.  Remember that time on machine is still the most critical factor . The whole waterfall effect takes TIME.  In Australia where John Agar is they prefer at least 24 hours weekly.
So whatever you do try to add time. My wife is half your size and has a lot less muscle yet she gets the same number of hours you get now. That is why her kt/v weekly runs over 3.0. on Nxstage.  Those 15 hours she gets clear her out as she only weighs 52kg.  You weigh twice that almost and so your 15 hours arent going to do as much.
You also have more muscle(i hope) and that creates more urea and creatinine.
You could consider addding time on your current system if they will let you. Another day would be helpful. Remember kidneys run 7 days per week. Missing 3 days puts a lot of stress on the body. 

[obsidianom]

AND ON A FINAL NOTE -------GO PATRIOTS!!!!!! --  BEAT DENVER!!!

[Simon Dog]

So if you weigh 100 kg , the safest speed would be max. 500 ml /hour or .5 liters per hour. 

More interesting data - please keep it coming.

I generally run in the 500ml to 600ml/hour range, much less on the days when I do two treatments without a day of in between.

I will ask my doc what he thinks about me adding another day to my current protocol.

Above that speed begins to stun the heart and avove 10ml/hour times weight which in this case would be 1 liter per hour, CAN BE DEADLY.

I ran at that sort of rate when I was new to D when I had an in-center appointment after the 2 day gap.  Avoiding that gap was one of the motivators for going to home treatment.

[Hemodoc]

The issue of osmotic gradients during dialysis and the "possible" contribution to intradialytic hypotension is tempered by the reality that Sodium modeling used so widely in American dialysis units to prevent lowering of the osmolality by increasing sodium levels in the dialysate is one of the largest contributors paradoxically to intradialytic hypotension by aggravation of interdialytic weight gains from net sodium accumulation. This is one of the biggest contributors of left ventricular hypertrophy seen in dialysis patients.

Today, the best practice is to match sodium levels in the dialysate to plasma sodium levels in the patient. The discussion in the HEMO post hoc analysis on osmotic shifts causing hypotension is first of all speculative since post hoc analysis of different factors outside of the original study parameters are NOT randomized and controlled as other factors in the original study hypothesis. I did not spend $38.00 to get the full article, but they did not control for how the Kt/V in the high study group were manipulated through various interventions such as different artificial kidneys with variable membrane characteristics, variable blood flow rates, variable dialysate flow rates before changing session lengths.

It appears that you have extrapolated the results to dialysate flow rates alone which is really a stretch on this article since their High Kt/V group had multiple manipulations of several independent factors. In addition, the entire juxtaposition of Dr. Agar's article on the waterfall of dialysis is a treatise against the very practices utilized in HEMO study, a very unique American modality of dialysis that focuses on Kt/V which by the way is a dimensionless calculation only. What exactly does a ratio without dimensions really mean? Dr. Agar makes this point right from the beginning in the title of his article: The Dialysis Waterfall (Forget Urea: It’s Fluid That Kills)

Far too much emphasis has been placed on an arbitrary and flawed concept—Kt/Vurea—to the detriment of all else.

Kt/Vurea was developed over 30 years ago after the publication of the NCDS study following 165 patients over 24-48 weeks of 1970's low-flux hemodialysis. None were over 60 and none were diabetic ... not quite a "normal" dialysis population.

Worse, all focus was on one small molecule, urea, thought then to best represent a marker of good clearance. While we now know that it would be hard to find a less representative "toxin" (its trans-compartmental kinetics bear little or no relationship or similarity to the behavioral kinetics of any of Vanholder's vast list of uraemic toxins), Kt/Vurea is still used in the US as the marker of "adequacy." What bunkum!

We now better understand the importance of middle molecules like β2M, homocysteine, and the hydrophilic envelope around tiny phosphate that turns it into a time dependent trans-membrane traveller. Even then, this focus implies that dialysis is all about solute clearance. Another myth. Bunkum again!. . .

Most commonly it is fluid, not solute, that maims and kills the dialysis patient. It is fluid that stifles the breath, stretches the heart past the zenith of Starling's curve, and—when removed—is commonly removed so fast that the blood pressure and circulation collapses, coronary and myocardial perfusion falls, and the heart is stunned. That sequence is not solute-related. Tick that up to fluid!

In the dialysis setting, when fluid is discussed, it is all too often in tones of anger and confrontation. Dialysis staff regularly berate patients over excess fluid gain (the surrogate phrase for non-compliance) without considering why. After all, it is the patients' fault. More bunkum!

http://www.homedialysis.org/news-and-research/blog/27-dialysis-waterfall-forget-urea

The majority of articles on how to treat intradialytic hyptension are generated here in America BECAUSE of our short, violent dialysis sessions with high volumes of rapid fluid removal. That is indeed the point of Dr. Agar's article the specific target of his article is unique American style dialysis protocols not found elsewhere in the developed nations.

Looking at how the HEMO study developed the differing Kt/V groups, a study from DOPPS by Saran et, al in 2006 points out a major flaw of the HEMO study:

Longer treatment time and slower ultrafiltration in hemodialysis: Associations with reduced mortality in the DOPPS

In our study, the association of longer TTs and lower mortality was strongest in Japan, followed by Europe and the US (Figure 3). Although the explanation for this somewhat differential gradient in the relationship by region is not entirely clear, it may be due in part to the fact that in Japan, Kt/V targets are more often achieved by prolonging TT, whereas in Europe or the US, reliance on blood flow rates and dialyzer size to achieve Kt/V targets may be more common.

http://www.nature.com/ki/journal/v69/n7/full/5000186a.html

The DOPPS article goes on to show that treatment time (TT) is perhaps the largest determinant of the incidence of intradialytic hyptension (IHD).  In the end, the post hoc analysis of the HEMO study on osmotic shifts leading to hypotension is an attempt to justify the American practice of sodium modeling in patients which is known today to increase the risk of cardiac injury. Matching the sodium to the plasma levels prevents this cycle of volume expansion during dialysis from high sodium loads leading to incredible thirst and huge weight gains between sessions. Once again, Dr. Agar dealt with this directly in his article above:


A Daily Scenario In Most Dialysis Units:
A patient arrives for dialysis with excess fluid to remove.

This is what tends to happen:

A (sometimes ugly) confrontation occurs with: "... you have not adhered to your fluid restriction ..."
With lots of fluid to remove, a high ultrafiltration rate (UFR) is required and set.
Surprise: the patient goes "flat" halfway through. Urgent "resuscitation" starts, with N saline (of course). But wait: isn't dialysis meant to be removing excess salt and water?
After loading up with salt and water, more fluid is taken off, and fast, for time is now short. Even if more flats are avoided, cramp is not and, at the end of dialysis, the patient is as limp as a potted plant at the end of a hot day ... and is grumpy ... and feels like death warmed up.
Before you is a patient with a maximally contracted circulating volume —to the point of circulatory collapse and hypotension. Before you is a patient with a maximally activated thirst mechanism. Thirst is an irresistible, primal, survival instinct buried deep in the brain stem. The patient is without a hope of suppressing it.
What, then, does the patient do? He/she drinks! So would you —you would have to! Your brain stem would insist on it! And so this "noncompliant" patient complies with the primal survival drive of thirst, and drinks!
In 2 days time (or 3, at the staff-convenient weekend), the patient returns, finally revitalized by fluid, but extra kilos "over". More angry berating ensues "You must be more compliant, you are killing yourself ..."
No ... we are the ones doing the killing.


Mind you, Dr. Agar DID NOT write this article for his colleagues in Australia or New Zealand. This is meant specifically for an American audience since this is a unique American treatment problem. So, if osmotic shifts have any part of IHD, not proven even after speculation of this issue for 30-40 years, it begs the question of why America ignores the most obvious cause, our short, fast and violent dialysis practices.

For the NxStage, even a max 300 ml/min dialysate flow rate is far below standard dialysate rates. Focussing on the Kt/V alone misses the essential message of Dr. Agar's treatise on fluid management in dialysis patients. It is an iatrogenic issue as Agar states above, No ... we are the ones doing the killing.

[Hemodoc]

So if you weigh 100 kg , the safest speed would be max. 500 ml /hour or .5 liters per hour. 

More interesting data - please keep it coming.

I generally run in the 500ml to 600ml/hour range, much less on the days when I do two treatments without a day of in between.

I will ask my doc what he thinks about me adding another day to my current protocol.

Above that speed begins to stun the heart and avove 10ml/hour times weight which in this case would be 1 liter per hour, CAN BE DEADLY.

I ran at that sort of rate when I was new to D when I had an in-center appointment after the 2 day gap.  Avoiding that gap was one of the motivators for going to home treatment.

The risk of more frequent dialysis is access issues. Unfortunately both frequency and total dwell time is associated with increased infections and other complications to the access. There appears to be many factors involved in this including integrity of the skin which is a barrier breached with each dialysis session. However, when looking at mortality and morbidity, despite potential increased access issues, mortality improves with each 30 minutes of additional dialysis as noted in the Saran article from DOPPS above. For those nephrologists who are enlightened on optimal dialysis issues, which is a minority of US nephs, the consensus appears to focus on 40 hours a week of dialysis as a reasonable target of the best you can do. Obviously, everyone must fit dialysis into their own personal goals outside of dialysis and other constraints, but for those who can accomplish this, they have the best outcomes.

Pauly et al in 2009 showed that nocturnal hemodialysis was equivalent in outcome with cadaveric transplant which opens up further discussion on the risk, benefits and alternatives for all renal replacement modalities in any given individual:

Survival among nocturnal home haemodialysis patients compared to kidney transplant recipients
Robert P. Pauly1, John S. Gill2, Caren L. Rose2, Reem A. Asad3, Anne Chery4, Andreas Pierratos5 and Christopher T. Chan3
+ Author Affiliations

Abstract

Background. Kidney transplantation is the gold standard renal replacement therapy. Nocturnal haemodialysis (NHD) is an intensive dialysis modality (6–8 h/session, 3–7 sessions/week) associated with a significant improvement of clinical and biochemical parameters compared to conventional dialysis. To date, no studies have compared survival in patients treated with NHD and kidney transplantation.

Methods. Using data from two regional NHD programmes and the USRDS from 1994 to 2006, we performed a matched cohort study comparing survival between NHD and deceased and living donor kidney transplantation (DTX and LTX) by randomly matching NHD patients to transplant recipients in a 1:3:3 ratio. The independent association of treatment modality with survival was determined using Cox multivariate regression.

Results. The total study population consisted of 177 NHD patients matched to 1062 DTX and LTX recipients (total 1239 patients) followed for a maximum of 12.4 years. During the follow-up period, the proportion of deaths among NHD, DTX and LTX patients was 14.7%, 14.3% and 8.5%, respectively (P = 0.006). We found no difference in the adjusted survival between NHD and DTX (HR 0.87, 95% CI 0.50–1.51; NHD reference group), while LTX survival was better (HR 0.51, 95% CI 0.28–0.91).

Conclusions. These results indicate that NHD and DTX survival is comparable, and suggest that this intensive dialysis modality may be a bridge to transplantation or even a suitable alternative in the absence of LTX in the current era of growing transplant waiting lists and organ shortage.

http://ndt.oxfordjournals.org/content/24/9/2915.abstract

[amanda100wilson]

Thanks, Peter.  Your input is much appreciated.   Am learning a lot.

[obsidianom]

Longer treatment time and slower ultrafiltration in hemodialysis: Associations with reduced mortality in the DOPPS

Peter, you and John both preach water is the killer as well as needing longer treatment times and slower UF. WELL NXSTAGE DOES ALLOW THIS. You may not like the dialysate speed but regardless it allows more frequent dialysis with more total time and consequently slower UF. Doing dialysis 5 days per week allows much less fluid removal and also slower speed of the removal.
If it really is water that kills then NxStage really is superior to the other home therapies as it is more frequent .Yes the dialysate is slower but since you guys both claim it is not urea that kills , but water then I stand by my point that Nxstage home therapy at 5 or 6 days per week solves the water issue nicely.

[obsidianom]

"For the NxStage, even a max 300 ml/min dialysate flow rate is far below standard dialysate rates. Focussing on the Kt/V alone misses the essential message of Dr. Agar's treatise on fluid management in dialysis patients. "  This is your quote from above.

The below is a quote from John Agar to me in an email.

"In contrast, we run our Qb at 225 ml/min = a much more sedate and AVF-friendly flow rate, I believe ...

Our standard single-pas Qd is 300 ml.min

This creates a Qd:Qb flow rate ratio of ~ 1.33."

NOW ISNT IT INTERESTING THAT HE RUNS DIALYSATE AT 300 ML/MIN AND NXSTAGE CAN NOW GO TO 300 ML/MIN.   So why not run Nxstage at max dailysate of 300 and blood flow rate at 225 or so like they do in Australia? Nxstage IS capable of this. Again I point out that this system can work quite effectively even cpmpared with John's "perfect" rates in Australia.  I realize we would need to max out the dialysate to near or at  60 liters to get enough time , but it is doable.  At 18 liters per hour (300 ml/min) Nxstage would need to run at least 54 liters to get 3 hours per treatment. Thats not a bad number for many.  60 liters would take 3 hours and 20 minutes.  At 5 days per week it would give a solid 16 hours and 40 minutes total.
So Nxstage can be run at eqivilant dialysate rates to what John uses in Australia. Nocturnal would be out but at least daytime would work well.

[Hemodoc]

Longer treatment time and slower ultrafiltration in hemodialysis: Associations with reduced mortality in the DOPPS

Peter, you and John both preach water is the killer as well as needing longer treatment times and slower UF. WELL NXSTAGE DOES ALLOW THIS. You may not like the dialysate speed but regardless it allows more frequent dialysis with more total time and consequently slower UF. Doing dialysis 5 days per week allows much less fluid removal and also slower speed of the removal.
If it really is water that kills then NxStage really is superior to the other home therapies as it is more frequent .Yes the dialysate is slower but since you guys both claim it is not urea that kills , but water then I stand by my point that Nxstage home therapy at 5 or 6 days per week solves the water issue nicely.

Dear Obsidianom,

Not sure what I would call here is preaching, hopefully I am basing my views not on my opinion alone, but well done studies over many years that are ignored for the most part by the American nephrology community.

You are right, urea in itself is not one of the more toxic components of the uremic condition. At least by our current understanding. Dr. Agar and the data that Dr. Agar bases this opinion is that Urea clears easily, but it is the more dangerous components of uremia such as high PO4, and middle molecules that mediate much of the damage of CKD along with p-cresol. The message is that measuring urea but ignoring the middle molecules and PO4 is the wrong emphasis. Now, solute clearances do matter so you must have the correct ratio's of blood flow to dialysate flow. NxStage reverses the usual 1.5-2.0 X BFR and so you must have high blood flow rates to get an "adequate" clearance. That is where the concept of "FF" came from instead of just setting a direct dialysate flow rate. Nevertheless, the ratios are just too low and very inefficient at the point of view of the patient.

Using Kt/V as a measure for comparison only, my 4+ hours on NxStage gains me less than 2/3rds the same clearance on a standard machine. I believe at 60 liters I could be about 90-95% of in-center clearances which coupled with the ultra-pure dialysate would be an advantage. However, the new portable machines, the FMC PAK and the Baxter VIVIA have near ultra-pure dialysate and much higher clearances. Where that plays out as best is probably yet to be determined, but in the minds of American nephrology folks, the higher Kt/V performances of these other machines, will make it hard for NxStage to compete in all likelihood.

So, no, it is not urea that kills to the best of our current knowledge.

[Hemodoc]

"For the NxStage, even a max 300 ml/min dialysate flow rate is far below standard dialysate rates. Focussing on the Kt/V alone misses the essential message of Dr. Agar's treatise on fluid management in dialysis patients. "  This is your quote from above.

The below is a quote from John Agar to me in an email.

"In contrast, we run our Qb at 225 ml/min = a much more sedate and AVF-friendly flow rate, I believe ...

Our standard single-pas Qd is 300 ml.min

This creates a Qd:Qb flow rate ratio of ~ 1.33."

NOW ISNT IT INTERESTING THAT HE RUNS DIALYSATE AT 300 ML/MIN AND NXSTAGE CAN NOW GO TO 300 ML/MIN.   So why not run Nxstage at max dailysate of 300 and blood flow rate at 225 or so like they do in Australia? Nxstage IS capable of this. Again I point out that this system can work quite effectively even cpmpared with John's "perfect" rates in Australia.  I realize we would need to max out the dialysate to near or at  60 liters to get enough time , but it is doable.  At 18 liters per hour (300 ml/min) Nxstage would need to run at least 54 liters to get 3 hours per treatment. Thats not a bad number for many.  60 liters would take 3 hours and 20 minutes.  At 5 days per week it would give a solid 16 hours and 40 minutes total.
So Nxstage can be run at eqivilant dialysate rates to what John uses in Australia. Nocturnal would be out but at least daytime would work well.

I believe that is John's settings for his nocturnal patients obtaining about 40 hours of dialysis a week. And yes, NxStage can indeed produce that ratio for a short period of time. For nocturnal, you would have an FF of 50% to run 60 Liters of dialysate with a BFR of 250 ml/min for an 8 hour run. Given that PO4 and middle molecules are TIME dependent, a direct head to head comparison of middle molecule clearances is in order since many people on NxStage for nocturnal treatments need PO4 supplements. TIME is the most important factor in many ways, but that does not diminish the aspect of solute clearances especially at the short daily dialysis times of 2-3 hours used with the 20-30 liters dosage most NxStage people utilize today.

So, while urea is not the essential component of uremia and not the goal of dialytic therapies, solute clearances of the other molecules does remain an important aspect. The message John is putting across is a critique of the American reliance on urea kinetics as a measure of "good" dialysis when it is anything but that. You can crank up the blood flow rate, put a larger kidney on the machine and get very high Kt/V measurements in 3 hours of in-center dialysis, but the patient is dead in 3 years or less. That is what John is advocating against. This is a unique American problem in many ways.

[obsidianom]

I think we are on the same wavelength here for the most part.
My defense of Nxstage is that of our CURRENT machines available it is the best we have I beleive.
When my wife was in center she felt horrible each treatment on the Fresenius machine.  That is without fluid being taken off. WE were offered and actually pushed to the Fresenius machine to take home. It would have been a max. of 4 days per week.
Based on how my wife felt on Fresenius machine and the fewer days of dialysis and the ease of setup and use on Nxstage (and no special electric or water systems) we chose to go with Nxstage. I have never regretted our choice.   She is doing so much better on Nxstage 5 days per week.
Now when newer systems come available in the future I will carefully look at them and also get your opinion . However who knows how long that will be. It could be years before we see that in the US as the FDA is slow at times.
 
By the way Fresenius just had over 100,000 dialysis machines recalled by the FDA.   That is a lot of machines in the US alone. 

Thank you for this enlightening discourse we have been involved in .
 

[Zach]

What are the clearances for the dialyzer used by NxStage?

In particular, what is the NxStage dialyzer's Middle Molecule Performance (mL/min)?
I have never been able to get that info from NxStage. --One can easily find that information for Fresenius dialyzers:
http://www.fmcna-dialyzers.com/pdf/Optiflux%20Product%20Brochure%20Section/101046-01%20Optiflux%20High%20Flux.pdf

Have any of you measured your β₂ microglobulin blood levels (mg/L)?
Reference range for non-ESRD is 1.0 -1.8

Inquiring minds would like to know.

 

[Hemodoc]

I think we are on the same wavelength here for the most part.
My defense of Nxstage is that of our CURRENT machines available it is the best we have I beleive.
When my wife was in center she felt horrible each treatment on the Fresenius machine.  That is without fluid being taken off. WE were offered and actually pushed to the Fresenius machine to take home. It would have been a max. of 4 days per week.
Based on how my wife felt on Fresenius machine and the fewer days of dialysis and the ease of setup and use on Nxstage (and no special electric or water systems) we chose to go with Nxstage. I have never regretted our choice.   She is doing so much better on Nxstage 5 days per week.
Now when newer systems come available in the future I will carefully look at them and also get your opinion . However who knows how long that will be. It could be years before we see that in the US as the FDA is slow at times.
 
By the way Fresenius just had over 100,000 dialysis machines recalled by the FDA.   That is a lot of machines in the US alone. 

Thank you for this enlightening discourse we have been involved in .
 

The prior FMC CEO, Ben Lipps told me in January 2012, it would be out by the of that year. The VP for research told me later it should be by July 2013. You are right, who knows when it will come to pass. The FDA is quite slow in granting approvals even when items in use in Europe and Australia years ago still can't get approval here. Something just not right.

No matter what machine, the basic concepts will remain the same. Likewise, I am not holding my breath waiting for the American nephrologist to become enlightened any time soon either.

[obsidianom]

Hemodial Int. 2014 Jan 19. doi: 10.1111/hdi.12125. [Epub ahead of print]

Which fluid space is affected by ultrafiltration during hemodiafiltration?

Tapolyai MB, Faludi M, Fülöp T, Dossabhoy NR, Szombathelyi A, Berta K.
Author information

Ultrafiltration (UF) is a common procedure performed during almost all dialysis sessions. During UF, several liters of fluid are removed; however, what proportion of this fluid is removed from which fluid space could not be clinically measured easily until now; we designed this study to evaluate the fluid spaces most affected by UF. This is a prospective cohort study of 40 prevalent chronic hemodialysis patients receiving thrice weekly hemodiafiltration (HDF). We measured the patients' fluid spaces using a whole-body bioimpedance apparatus to evaluate the changes of fluid spaces before and immediately after the HDF sessions. We recorded the data on fluid spaces, UF volume, and blood pressures. The cohort consisted of 40 prevalent HDF patients, aged 60.0 ± 5.2 years (37.5% men; 27.5% people with diabetes), and body weight 71.03 ± 15.48 kg. Achieved UF was 2.38 ± 0.98 L on HDF (measured fluid overload: 2.35 ± 1.44 L). The extracellular fluid (EC) volume decreased from 16.84 ± 3.52 to 14.89 ± 3.06 L (P < 0.0001) and intracellular fluid (IC) volume from 16.88 ± 4.40 to 16.55 ± 4.48 L (P = 0.45). Although urea volume of distribution remained effectively unchanged (31.38 ± 7.28 vs. 30.70 ± 7.32 L; P = 0.45), the degree of EC volume overload decreased from 13.60% ± 7.30% to 3.83% ± 8.32% (P < 0.0001). The mean arterial pressure also decreased from 122.95 ± 19.02 to 108.50 ± 13.91 mmHg (P < 0.0001). We conclude that source of net fluid loss by ultrafiltration is almost exclusively the EC fluid space. The intracellular fluid space is not significantly affected immediately after HDF.

© 2014 International Society for Hemodialysis.

This is a very interesting study. I go back to my posts of Jan 17/18 on this thread I write about osmosis rates from compartment to compartment. This study actually shows that with standard machines UF removes water initially only from the extracellular compartment. By doing that fast I beleive they are creating an osmotic gradient that must then shift to equilibrate. Perhaps this is why so many patients feel so awful when UF is done quickly. Also how about measuring the molocule changes from compartment to compartment. That would be interesting.
So again, with Nxstage dialyzing 5 days per week, less fluid is removed per treatment and can be done slower/gentler. This study at least indicates this is a better way to go . It also backs John Agars blog on waterfall concept of fluid removal. Too fast is deadly.

[Hemodoc]

Certainly, post dialysis fatigue (PDF) is a multifactorial issue as just about everything in dialysis. However, there is developing and confirmed evidence that recurring myocardial ischemia related to excessive ultrafiltration rates and collapse of the ECF, cardiovascular system with low perfusion of blood to the heart is the primary event causing  PDF.

Association of segmental wall motion abnormalities occurring during hemodialysis with post-dialysis fatigue

Background Post-dialysis fatigue (PDF) is a common, debilitating symptom that remains poorly understood. Cardiac wall motion abnormalities (WMAs) may worsen during dialysis, but it is unknown whether WMA are associated with PDF.

Methods Forty patients were recruited from University of California San Francisco-affiliated dialysis units between January 2010 and February 2011. Participants underwent echocardiograms before and during the last hour of 79 dialysis sessions. Myocardial segments were graded 1–4 by a blinded reviewer, with four representing the worst WMA, and the segmental scores were summed for each echocardiogram. Patients completed questionnaires about their symptoms. Severe PDF (defined as lasting >2 h after dialysis) was analysed using a generalized linear model with candidate predictors including anemia, intradialytic hemodynamics and cardiac function.

Results Forty-four percent of patients with worsened WMA (n=9) had severe PDF, compared with 13% of patients with improved or unchanged WMA (P = 0.04). A one-point increase in the WMA score during dialysis was associated with a 10% higher RR of severe PDF [RR: 1.1, 95% CI (1.1, 1.2), P < 0.001]. After multivariable adjustment, every point increase in the WMA score was associated with a 2-fold higher risk of severe PDF [RR: 1.9, 95% CI (1.4, 2.6), P < 0.001]. History of depression was associated with severe PDF after adjustment for demographics and comorbidities [RR: 3.4, 95% CI (1.3, 9), P = 0.01], but anemia, hemodynamics and other parameters of cardiac function were not.

Conclusions Although cross-sectional, these results suggest that some patients may experience severe PDF as a symptom of cardiac ischemia occurring during dialysis.

http://ndt.oxfordjournals.org/content/early/2013/06/05/ndt.gft097.abstract

[obsidianom]

Very interesting article. thank you.
I was actually taking off fluid today on my wife which is very rare. She seemed to drink a lot lately and overwhelmed her kidneys. I could here her all night breathing hard last night and she had trouble on the treadmill breathing. She had gained about .5 kg which is alot for a 52 kg woman.  I followed John Agars fromula for UF speed . 52kg times 5ml/hour .  That gave about 250 ml/hour UF speed. That was quite gentle on her . I took off .3 liters to be conservative as I can take off more tomorrow as we dialyze again tomorrow. That is one advantage to our Nxstage system .We dialyze more frequently and can be more gentle and conservative when taking off fluid as there is usually tomorrow.
The best part is she felt better after dialysis and was breathing better with no cramping or feeling washed out. 

[Simon Dog]

The Fresenius 2008h/k/t series "recall" is because of the saline bag filling with dialysate during prime/setup if the drain line is clogged.  It is not a "recall" per say but a Level II - notification to all users. I received the letter (http://www.nephrologynews.com/ext/resources/files/saline-bag--HHD.pdf) along with a form I was asked to sign and fax or return confirming I received the letter.