hypotension

[carson]

Yesterday I woke up after 7 hours of dialysis (hemo) and felt really sick, dizzy and hot. I knew right away that I had removed too much fluid so I gave myself some saline. A litre later I still didn't feel too good but managed to get up. My BP was 69/51 but my weight was bang on. What this tells me is that my machine must have a calibration problem as, somehow, I ended up being 1000 ml too dry. According to my poor hubby (who really doesn't deserve this crap) I blacked out though I don't remember missing anything. My dialysis nurse was very upset and said I could have died. Anyone else have this happen? Are they over reacting? Or should I take it a little more seriously?

[KICKSTART]

Wasnt that classed as crashing ? I havent dont it yet but im on daytime hemo so keep a close eye on things. Ive seen a lot of the older people crash who dont want to know anything about there treatment. I certainly dont know about dying ? that seems a bit drastic ? If your bp was so low , maybe its time to adjust your dry weight ? when did you last have that done? sounds like you are pulling off to much fluid so maybe its time to up your dry weight?

[greg10]

This is a complicated subject and I would venture to say that a lot of dialysis nurses and nephrologists do not understand how ultrafiltration (UF) works in the Fresenius system versus the Hospal system.  The problem with both of them is that current technology is primitive and provides no feedback mechanism to adjust UF targets when the RBV (relative blood volume) and blood pressure changes during dialysis.  This is probably the single most important reason that the FDA has not approve any form of home hemodialysis for nocturnal purposes.  The following text is complicated but may be worth reading.  If there is any dialysis nurse or neph out there willing to take a crack at explaining this, please feel free to jump in.

I am no fan of the UF in the Fresenius system because I have seen first hand how it can knock you out even in an in center short duration session.  I can only say the NxStage system if used correctly will minimize this problem (UF limit is 1.5L/hr vs the 2.0L/hr of Fresenius, although we have never tried to go that high).

http://tinyurl.com/2unczkx

From Google books view of the book Clinical Dialysis by Allen Nissenson pp 74
http://www.amazon.com/gp/product/007141939X/ref=olp_product_details?ie=UTF8&me=&seller=

[del]

Hubby has been using a fresenius machine for nocturnal for the past 4 years.  His blood pressure has dropped a few times but he has never blacked out. We have just upped his dry weight and he has been fine.  We do find though - and it was like it in center as well - that when he gains or loses weight he can gain a couple of kilos before he sees a difference in his blood pressure and then boom!!  It will go either up or down very quickly.  Once we make the weight adjustment he is fine again.

If you adjust your weight and still crash it could be a calibration problem but we have never had any problems with fresenius and calibration.

[carson]

...but that's just it, del...my dry weight is perfect. This is a one time thing. This morning I woke up with my weight at 46 kg as usual but I had to fool the machine and not take off as much as I should have. The numbers I put into the FORMULA, not FRESENIUS, machine weren't accurate according to my math, but still I came off at the appropriate weight. I had a tech come to my home and recalibrate the UF so that it worked perfectly. As it turned out, the UF calibration WAS off, as were the blood level and air detected alarm calibrations. He said it can creep up over time. The last time I had a recalibration was a few years ago.

@ greg10 - I live in Canada where we have nocturnal home hemo

@Kickstart - yes, this was in fact crashing...apparently when the blood doesn't get to your brain due to hypotension you can die. I was told this years ago when I was on PD and refused Epo because of my fear of needles. My BP was SO low due to anemia that my neph said I could pass out whilst driving and die, and not just because I'd crash.

[del]

Glad you got it sorted out!!!  Nothing worst than too much fluid coming off!!

[calypso]

Yesterday I woke up after 7 hours of dialysis (hemo) and felt really sick, dizzy and hot. ... My dialysis nurse was very upset and said I could have died. Anyone else have this happen? Are they over reacting? Or should I take it a little more seriously?

Why were you on for 7 hours straight? Do you not do home hemo 7 days a week? Here home hemo on the NxStage is 2-3 hours a day for 5 to 7 days a week.

No they are not overreacting. Yes you could die. That is why here in the states, by law, you are not allowed to do home hemo alone. A partner is required or you will not be approved for home hemo. Not sure if this is a state law or federal law, but no matter, at least in my state, a partner is required to perform the task of either reviving you, or calling emergency services if something goes wrong. Not enough oxygen to a vital organ such as the brain is certainly a cause for concern, requires immediate action and is potentially (if left untreated) fatal.

[Bruno]

I agree with the comment on being careful with your dry weight but I see that you have that possibility covered (although at 46kg you can't have much room to move!) so all I can do is make two points my centre made to me before I go home to dialyse myself.
My training nurse said it was not good enough for me to give saline myself I needed to have somebody to do it in case I couldn't. Which stunned me because I just hadn't envisaged that scenario...and now I see your post.
The second thing she showed me was the Fresensius variation between the speed the blood pump shows and "effective speed'.
I was going to run at 250, but she said I would need to set the BP speed at 275 to achieve that.
Don't know if this helps and really really sorry you had that experience.

[greg10]

I just want to say I think you few nocturnal hemodialysis practitioners in Canada, Carson, Del & hubby are some of the bravest people I have come across.  I am glad everything is working out well. 

I thought I would pass along some of the recent findings:

(1) Rapid fluid removal during dialysis is associated with cardiovascular morbidity and mortality.  The title and content of this article described that you should not exceed 10 ml/hr/kg, which means for someone 46 kg, for example, you should not exceed 460 ml per hour in ultrafiltration.  Most dialysis machines seem to have a UF profile that automatically starts with a high UF rate and then taper off to low UF, frequently exceeding what you thought you might have set.
http://ihatedialysis.com/forum/index.php?topic=20596.0

(2) Patient and Technique Survival among a Canadian Multicenter Nocturnal Home Hemodialysis (NHD) Cohort.  This study showed that NHD practiced in Canada has "excellent" survival rate, although "14.6% experienced death or technique failure" (yikes, hopefully less death and more survivable technique failures.

Results:A total of 14.6% of the cohort experienced death or technique failure. Unadjusted 1- and 5-year adverse event-free survival was 95.2 and 80.1%, respectively. Significant predictors of a composite of mortality and technique failure included advanced age (P < 0.001), diabetes (P < 0.001), central venous catheter use (P = 0.01), and inability to perform NHD independently (P = 0.009) and were adjusted for center effect. Weekly frequency of NHD was not predictive. Age and diabetes remained significant with multivariable analysis (hazard ratio 1.07 and 2.64, respectively). Unadjusted 1- and 5-year technique survival was 97.9 and 95.2%, respectively. Only age was a significant predictor of technique failure.

Conclusions: NHD is associated with excellent adverse event-free survival. This study underscores the importance of modality-specific predictors in the success of home hemodialysis, as well as favorable baseline characteristics such as younger age and the absence of diabetes.

http://cjasn.asnjournals.org/cgi/content/abstract/5/10/1815

[carson]

Update: the tech came up and recalibrated my whole machine. The UF was WAY off and that's why I crashed. Since it's been fixed everything is fine and I just go about my treatments without worry. He also fixed my blood level calibration, my air detection calibration and my temperature.  I was always FREEZING whilst dialyzing and I wear: sock, tshirt, flannel pjs, electric blanket, goose down duvet, comforter and a sheet thoughout the night - all year round. Even in the summer when it's roasting out. Now I'm snug as a bug!

@calypso - I do 7 x 7 because it's at a VERY slow rate and much better for the body than just 2 or 3 hours. In fact, at this rate the body barely even realizes it has kidney failure and every other body function is on target. Also, having a partner is imperative! I couldn't and wouldn't do this at home without him!! Currently I'm training him to set up the lines and hook me up to the machine in case I ever feel sick with the flu or something. I'm scared to death he might make a mistake and I'll pay for it, but he's pretty amazing so HOPEFULLY it'll be ok!

@ greg10:  thanks for all the info! That's truly amazing!