KTV

[JohnJ]

My clinic is upset my KtV hovers under 2.0 however I work 4 or 5 days a week for FedEx delivering 60+ packages a week. Everything I've read says the KtV is at best nothing but a indication of how clean your blood is and no indication of how healthy you are. How can they claim I'm not healthy when I'm doing more physical activity than 99% of dialysis patients? They are saying that they will be forced by the powers that be to make me go back to in clinic dialysis. Then I lose my job. It's because I'm working so hard my KtV is low...more physical activity is going to make your blood dirtier. That's just the way the body works.

By the way I'm on 5 days a week using 26 liters for each treatment.

Anyone having the same problem?

[boswife]

i'' be anxious to hear any replies on this.  The part that really bugs is that you say  they can have th power to make you go back to center if you dont want to.  Can that be?  I woudl think that they woud just have to adjust your treatments so they get the numbers they want.

[greg10]

Hi John and welcome to the forum.  We appreciate your good work in your service to our country and now in the private sector.

AFAIK, kt/v has nothing to do with how hard you work and how good you feel.  It has everything to do with how well your clearance of urea has been during dialysis.  It is a function of time (you didn't say how long you dialyze), frequency of dialysis (5 per week in your case), the volume of your total body fluid (from your weight) and the urea presence before and after dialysis.

I will venture to guess that you are a big guy (more fluid) and you may be running your blood flow a little fast and doing the dialysis a little too quickly.  You may have to slow down and dialyze longer with more dialysate.  What you are doing may have a good kt/v for a physically smaller person, but for you, it may be inadequate.

So it is not just the frequency (5/week is good), but also how well you dialyze during that time given your weight.

ktv calculator
http://www.davita.com/tools/ktvcalculator/

[Bill Peckham]

My clinic is upset my KtV hovers under 2.0 however I work 4 or 5 days a week for FedEx delivering 60+ packages a week. Everything I've read says the KtV is at best nothing but a indication of how clean your blood is and no indication of how healthy you are. How can they claim I'm not healthy when I'm doing more physical activity than 99% of dialysis patients? They are saying that they will be forced by the powers that be to make me go back to in clinic dialysis. Then I lose my job. It's because I'm working so hard my KtV is low...more physical activity is going to make your blood dirtier. That's just the way the body works.

By the way I'm on 5 days a week using 26 liters for each treatment.

Anyone having the same problem?

It doesn't make sense that anyone would want to force you back incenter due to your Kt/V. The only clearance measure used for reimbursement is URR, as of this year, and people who dialyze at home are excluded from being counted.

It's nonsensical unless they're assuming you're not following your dialysis prescription.

[JohnJ]

Hi John and welcome to the forum.  We appreciate your good work in your service to our country and now in the private sector.

"you are a big guy (more fluid) and you may be running your blood flow a little fast and doing the dialysis a little too quickly

ktv calculator
http://www.davita.com/tools/ktvcalculator/

I'm 5'10" and weigh 210. That's down from 225 when I started. The funny thing is that as became more physical (because of the job) my KtV has gone DOWN and they are saying this is a problem. How can being in better shape than most 52 year olds be bad?

My fluids are fine. They check that every month and I am NOT retaining fluid. Again, because of my medical background I feel I'm more capable of watching my condition than most. Add to that that I had a liver transplant back in 2003 so I've been watching my condition closely long before my ESRD appeared.

[JohnJ]

It doesn't make sense that anyone would want to force you back incenter due to your Kt/V. The only clearance measure used for reimbursement is URR, as of this year, and people who dialyze at home are excluded from being counted.

Could you cite that for me? I'd really like to be able to show them that I know the facts about this instead of just saying I read it on a Internet board.

BTW I'm with RIA (if that makes a difference) and it's Medicare they are saying is raising hell about my KtV.

[silverhead]

Believe me, when Bill Peckham speaks, that is the authority,  go to his website http://www.billpeckham.com and you will find a wealth of info.......

[M3Riddler]

My clinic is upset my KtV hovers under 2.0 however I work 4 or 5 days a week for FedEx delivering 60+ packages a week. Everything I've read says the KtV is at best nothing but a indication of how clean your blood is and no indication of how healthy you are. How can they claim I'm not healthy when I'm doing more physical activity than 99% of dialysis patients? They are saying that they will be forced by the powers that be to make me go back to in clinic dialysis. Then I lose my job. It's because I'm working so hard my KtV is low...more physical activity is going to make your blood dirtier. That's just the way the body works.

By the way I'm on 5 days a week using 26 liters for each treatment.

Anyone having the same problem?

Bill P is right, they cannot force you to go back in center due to Kt/v dropping. What was your kt/v before?  How are your other labs?  BUN, creatinine, phosphorus and postassium? 
Are you on NxStage?  Also, how are they calculating your kt/v? there are several formulas.
Aslo, Kt/v is just one measure of adequacy and many nephrologists do not rely on kt/v.
Is there anything else beisides the kt/v that they are basing things off of? Are you missing treatments, cutting treatments short? Did a nurse or nephrologists state to you that you would have to go back in center? I would ask for the documentation or policy that they are making their decision off of and then provide them with information that states otherwise.....I would suggest that you research the laws/policies yourself and become familiar with them to support your home dialysis.
If this continues, I would also suggest looking for another center if any are around your area.  How long have you been on home dialysis? How is your URR? and other labs ?  If your kt/v has dropped, then your nephrologist should be adjusting your prescription for better dialysis. Seems like your center/nephrologist is falling short and not doing their job by optimizing your treatment for better results.....

[Bill Peckham]

It doesn't make sense that anyone would want to force you back incenter due to your Kt/V. The only clearance measure used for reimbursement is URR, as of this year, and people who dialyze at home are excluded from being counted.

Could you cite that for me? I'd really like to be able to show them that I know the facts about this instead of just saying I read it on a Internet board.

BTW I'm with RIA (if that makes a difference) and it's Medicare they are saying is raising hell about my KtV.

The Quality Incentive Program was mandated by MIPPA, the three measures to be used were published as part of the proposed rule on expanding the payment bundle


The second comment period was on the details of how the three measures would be used - here is a breakdown of the proposal

The three measures have been finalized as part of the first rule making process but the second rule making process has not been finalized - so we don't know for sure what the weights and reporting requirements will be but we do know the three measures.

As far as home dialysis goes the rule makes clear that they will use UMKECC methodology in determining who is counted under the various measures  - looking at UMKECC methodology (you can see examples of Dialysis Facility Reports) they don't include PD or people dialyzing more than 3 times a week when calculating URR thus people at home won't be included in the QIP.

Renal Advantage is part of Kidney Care Partners,. they have access to detailed analysis of the proposed rule, so just ask the person at your unit to clarify what they're saying with corporate.

But this all applies to people who are Medicare primary, we're the only ones who could have up to 2% of our reimbursement withheld in 2012 if the unit doesn't meet the QIP standards in 2010. You must be covered under an Employer Group Health Plan - FedEX, and there is the VA so I'm not sure you'll be Medicare primary once the 30 month Medicare Secondary Payer period is up. In practicle terms this should mean that your unit will bend over backwards to accommodate you -

it just doesn't make sense that they're giving you grief - It doesn't make sense clinically (the key metric is how you feel) and it doesn't make sense reimbursement wise (how many treatments a week are they being paid - for all five or for just three?)

[JohnJ]

Bill P is right, they cannot force you to go back in center due to Kt/v dropping. What was your kt/v before?  How are your other labs?  BUN, creatinine, phosphorus and postassium?

Before I started working it was around 2.6. Now it's under 2 the last 2 months.

Are you on NxStage?  Also, how are they calculating your kt/v? there are several formulas.

No idea.

Aslo, Kt/v is just one measure of adequacy and many nephrologists do not rely on kt/v.

Funny you should mention that. We've had several discussions about KtV not being a reliable indicator of health and he still wants to throw it in my face each time. I finally did enough research last month...that discussion will now cease.

Is there anything else beisides the kt/v that they are basing things off of? Are you missing treatments, cutting treatments short? Did a nurse or nephrologists state to you that you would have to go back in center? I would ask for the documentation or policy that they are making their decision off of and then provide them with information that states otherwise.....I would suggest that you research the laws/policies yourself and become familiar with them to support your home dialysis.

On average I miss a treatment every other week due to illness (I've had a liver transplant the the suppressants cause me to have colds and flu(s) occasionally. The problem is the NURSE complains every time I use bags. So it's either skip or use bags. Either way I get hassled.

If this continues, I would also suggest looking for another center if any are around your area.  How long have you been on home dialysis? How is your URR? and other labs ?  If your kt/v has dropped, then your nephrologist should be adjusting your prescription for better dialysis. Seems like your center/nephrologist is falling short and not doing their job by optimizing your treatment for better results.....

Looking for another center has entered into the conversation. They backed off for a while. THEIR problem is they only have 3 home hemo patients..it's hard to find ESRD patients in Alabama than can handle home hemo. They just aren't smart enough (I'm not from Alabama).

They have NOT suggested adjusting my prescription so they really don't have a leg to stand on.

Thanks for the input. I'm trying to find a nice way of telling them "Hey..I'm fine. I'm doing better than any other of your dialysis patients so kindly FO.

[JohnJ]

But this all applies to people who are Medicare primary, we're the only ones who could have up to 2% of our reimbursement withheld in 2012 if the unit doesn't meet the QIP standards in 2010. You must be covered under an Employer Group Health Plan - FedEX, and there is the VA so I'm not sure you'll be Medicare primary once the 30 month Medicare Secondary Payer period is up. In practicle terms this should mean that your unit will bend over backwards to accommodate you

I'm BC/BS primary under my wife's insurance. I'm only a temp with FedEx. I can't handle 5 days a week and not use bags.

it just doesn't make sense that they're giving you grief - It doesn't make sense clinically (the key metric is how you feel) and it doesn't make sense reimbursement wise (how many treatments a week are they being paid - for all five or for just three?)

You have to understand that this is Alabama. The physicians are NOT used to being questioned by the patients. They're not used to a patient being as involved as I am.

You should have heard the fight I had with liver transplant because I refused to go to a 12 step program because I had a beer IN THE LAST YEAR before my medical board. Had to threaten them with a lawyer because I wouldn't go into a faith based program. THAT was a fun fight!

[Bill Peckham]

I appreciate that zip code is probably the number one determinate of dialysis care options.

A two days on, one day off schedule might be a good fit ... maybe 30L, two days on, two days off. It works out to 4.66 days a week.

I think the underlying issue is using bags and the Kt/V is just a convenient cudgel. If you're private pay they should just suck it up. Do you look at your Explanation of Benefits? Is BCBS paying for every treatment ~5 week?

[tyefly]

I am on home treatment too.... with Nxstage.... when I was training they were having me use 20 L....and after several weeks I started to feel worse than I felt when I was in center.....  and my Kt/v went down too....  I asked for more dialysate and they took me up to 30L....  I weigh about the same as you so I think at this body weight we need more time and dialysate.....Plus I work to and I am really active..... 

Do your self a favor and ask for dialysate and time on the machine.....you will feel better in the long run.....  dont let them push you around... my clinic was pretty new to the home treatment and not familar with nxstage either....  I am currently pushing for noctural.....  which is were I think everyone should be.....

[vcarmody]

My husbands KT/V has never been good. We currently do 5 treatments a week 25 liters at a 30 FF his KT/V is about 1.6 to 1.9. His nurse is always saying its not good and it has to get up to 2.2. His doctor says all his blood work is good. We were doing 6 treatments a week 25 liters FF35 but we pushed for 5 days a week because my husband insist the more he does dialysis the sicker he feels. I have to agree with him. He feels so much better now that we reduced his treatments and lowered his FF (it actually pretty much works out to the same amount of treatment time as it did when we were on six days a week). The doctor says the nurse is not figuring my husband kidney function into the KT/V formula. His kidney function is still around 9-10%. Also my husband is a big guy just under 300 lbs. When we wanted to go.to 5 treatments a week the doctor went over all his numbers and approved it.  Just two weeks before we asked the doctor to go to 5 treatments a week my husband was cornered while at the clinic by his nurse and the manager they were telling him he was gonna have to go back in center cause we signed a contract saying we would do 6 treatments a week not 5. I think they were upset they were losing the 720.00 they charge per treatment.  Yes our insurance pays for every treatment 720.00 a treatment  and that is just the treatments, they pay extra for EPO shots and bloodwork.

[tyefly]

Sounds like you may need to do more dialysate.... Like  30 L  or  40 L with that body weight.....  if you increase the amount of dialysate  it will increase your time everyday.... but  you will feel way better..... I did after I went from 20 to 30.....    I am doing 4.5 hours a day  5 or 6 days a week.....  just depends on what I want to do... dont let them push you away from Nxstage....... its worth the extra time.....

[Bill Peckham]

I think you have it exactly right vcarmody go with what works. As long as the doc is on board the staff will just have to find another way to jack up their bonuses.

[Rerun]

My center (or someone in upper management) is upset because my KT/V is too high.  I'm at 5.7     I'm too clean and they don't understand?

I'm on Nocturnal 3 nights a week so I get 24 hours of cleaning.   They are never happy unless we are RIGHT where they want us.  Just sick enough not to bitch.

   

[vcarmody]

Rerun I think you hit the nail right on the head.  I'm pretty sure my center hates me (and I owe it to this site and the knowledgeable people here) because I question everything they do if It don't sit right with me.  I mean hell this is my husbands life there playing with.  And yes, I think they do want you sick, because every time my husbands starts feeling really good they go and change something to make his feel like crap again.  Go figure!