Phosphorus

[carson]

I know most dialysis patients have to watch their calcium/phosphorus levels but I seem to have an unusual problem. I do nocturnal home hemo, 7 days/wk, 7-7.5 hrs/night.
My phosphorus is too low and I can't seem to get it higher. I eat nuts, chocolate, cheese, dairy, diet coke, whole grains but no luck. My nurse said it's the reason I'm so tired. Any advice will be appreciated.
Lisa

[Jie]

There are phosphorus supplements available and a lot of transplant patients have low phosphorus levers and need to take supplements.

[Cordelia]

My levels are on the  higher side. I sure wish I could eat those foods you mentioned.

[greg10]

I know most dialysis patients have to watch their calcium/phosphorus levels but I seem to have an unusual problem. I do nocturnal home hemo, 7 days/wk, 7-7.5 hrs/night...

May I ask why you are doing "so much", I know that term is relative, dialysis?
Your HDP (Hemodialysis product), based on Scribner and Oreopoulos, is 7 x (7)^2 or 7*7*7 = 343, which is higher than anyone I know and you don't look like you weight very much.  HDP of 343 is kind of in an uncharted territory, at least based on the data in 2004.

Compared to someone doing thrice weekly in-center, their HDP = 3*3*3 = 27.



The Hemodialysis Product
Based on published evidence from many sources, we propose a new index of adequacy of hemodialysis, to be called the
Hemodialysis Product (HDP). This new index incorporates dialysis frequency, which is an important variable:

HDP = (hrs/dialysis session) x (sessions/wk)^2

[Zach]

HDP of 343 is kind of in an uncharted territory, at least based on the data in 2004.

Compared to someone doing thrice weekly in-center, their HDP = 3*3*3 = 27.

greg10 makes a good point.

Plus with all that hemodialysis you may need other additional micronutrients, protein and calories than a typical person on dialysis.

[RightSide]

I know most dialysis patients have to watch their calcium/phosphorus levels but I seem to have an unusual problem. I do nocturnal home hemo, 7 days/wk, 7-7.5 hrs/night.
My phosphorus is too low and I can't seem to get it higher.

I dunno.

Even if you're dialyzing that much, with the type of foods you're eating your phosphate level shouldn't be low.  Especially Diet Coke, whose phosphorus bioavailability is very high.

Is your PTH under good control?  High PTH and inadequate vitamin D can cause both calcium and phosphorus to leach out of the bones.  What was your last PTH reading?

You're not consuming anything that has aluminum in it (like some liquid antacids), are you?  Or using antiperspirants that contain aluminum chlorhydrate on broken skin?  Dialysis doesn't remove aluminum, and aluminum toxicity can cause phosphorus deficiency.

[carson]

Okay, why do I dialyse so much?
Initially I was told to do 3 days on, 1 day off approx 8 hrs/night. I found I couldn't sleep without the noise of the Formula machine running, and it was also affecting my husband's sleep. I also felt almost addicted to dialysis...crazy, I know. So that's why I do it so much. The dialysis nurse has asked me to cut back as I'm becoming slightly malnourished despite my high protein, high phosphorus, and very good diet.
My PTH is good (can't remember what my last reading was but it was "normal") but I take 30 mg Sensipar daily. I also take Rocaltrol once/week. It's a vitamin D concentrate. And, Replatvite which is a renal vitamin.
AND I add phosphate to my dialysis each night.

I guess my concern is the effect low phosphorus will have on my body over time. I try to stay as healthy as I can but this is new to me after 14 yrs on dialysis.
I appreciate all your input!
Thank you!!

[carson]

Rightside, while I don't use any aluminum products I find what you mentioned about it very interesting! I don't even use aluminum pots or pans...but I'm wondering if I should maybe have my aluminum levels checked. I remember when I was on PD there was a problem with the dialysate containing aluminum and it was recalled.
thanks for this!

[Rerun]

Cut back to 3 days on and 1 day off.  Get a FISH TANK for your room for noise.  HOLY CRAP you are going to dialyze all the good stuff out too. 

[Ken Shelmerdine]

Cut back to 3 days on and 1 day off.  Get a FISH TANK for your room for noise.  HOLY CRAP you are going to dialyze all the good stuff out too.

Or, get a computer, put two recording mikes either side of your machine and record onto the computer about 30 seconds of the machine sound. Connect the computer to some hi-fi speakers and set it for loop playback all night. Anything instead of all that dialysis.

[Zach]

I say make that day-off on Saturday evening and then you and your husband go out and party!
Return at 4 am and both of you will sleep through the morning.

 

[calypso]

May I ask why you are doing "so much", I know that term is relative, dialysis?
Your HDP (Hemodialysis product), based on Scribner and Oreopoulos, is 7 x (7)^2 or 7*7*7 = 343, which is higher than anyone I know and you don't look like you weight very much.  HDP of 343 is kind of in an uncharted territory, at least based on the data in 2004.

Compared to someone doing thrice weekly in-center, their HDP = 3*3*3 = 27.

The Hemodialysis Product
Based on published evidence from many sources, we propose a new index of adequacy of hemodialysis, to be called the
Hemodialysis Product (HDP). This new index incorporates dialysis frequency, which is an important variable:

HDP = (hrs/dialysis session) x (sessions/wk)^2

First of all to the OP, your question about low phosphorous went unanswered. I believe low phosphorous may be just as harmful as high phosphorous so I would not take this lightly and try to get it normalized as soon as possible. Don't just ignore it thinking if high phos is bad low must be good.

Also, I almost forgot, there are different dialyzers you can use. Has your unit informed you of this? For example, at my unit if you are doing 4 hours of dialysis per session (daytime, during training) we use a different dialyzer than when you're on for 6-8 hours at night at home. Reason being the dialyzer we use for longer duration dialysis is gentler at removing toxins than the 4 hour short session more aggressive type. The length of the dialyzer is different affecting how long the dialysate is counter flowing against the blood removing the toxins (and fluid). There are several kinds of dialyzers and even different brands you can try, with your units approval of course. You might want to ask them about it.

Greg10 HDP sounds interesting but I don't see how it takes blood pump speed into consideration. At my unit we look at total blood volume processed, which the Fresenius machine calculates for you. For example if I have a blood pump speed of 300 (ml per minute) for 6 hours that would be 0.3 (liters per minute) x 60 (minutes per hour) x 6 (hours per night)= 108 liters of blood processed (run through the dialyzer). Mutliply that by 6 nights (standard for my nocturnal home hemo unit) that would be 648 liters of blood processed a week.

Compare that to a patient in a standard thrice weekly dialysis unit let's say they do the usual 3 and a half hours per session with a blood pump speed of 400, that would be 0.4 (liters per minute) x 60 (minutes per hour) x 3.5 (hours per session)= 84 liters of blood processed multiply by 3 days a week and that is 252 liters of blood processed per week. Also that 400 pump speed can't be as good for the fistula as 300. but they are trying to cram it all in small time slots. Understandable, just not ideal...or even adequate in my opinion, but thats going off topic, so I'll leave it at that.

[greg10]

..

Greg10 HDP sounds interesting but I don't see how it takes blood pump speed into consideration. ..

Correct.  You can say that the late Dr. Belding Scribner wrote the book on adequacy of dialysis and HDP is a good but not perfect indicator, for example it does not take blood flow into account and it doesn't take into account patient weight as well.  However, it is still a very good indicator of adequacy of dialysis and some may say it is better than kt/V currently being used.

Good interview with Dr. Scribner.
http://www.laskerfoundation.org/awards/2002_c_interview_scribner.htm

BTW, Calypso, good job on getting home dialysis going with your Fresenius baby K.  Make sure you don't hook up the water lines incorrectly as it happened to this poor lady:

Catastrophic hypercalcemia as a technical complication in home hemodialysis
http://ndtplus.oxfordjournals.org/content/early/2011/04/11/ndtplus.sfr051.abstract
Abstract

Life-threatening hypercalcemia in dialysis patients is very unusual. We present a case where life-threatening hypercalcemia in a home hemodialysis patient resulted from a technical mistake. A 46-year-old woman, on home nocturnal hemodialysis, presented to the emergency room with history of altered sensorium, vomiting and sweating, which started 1 h after initiation of dialysis the previous night. Serum calcium was 6.5 mmol/L. She improved with 10 h of low-calcium hemodialysis. Investigation revealed that the drain port of the reverse osmosis machine was connected to the dialysis machine and the product water was connected to the drain leading to acute hypercalcemia.

[calypso]

Investigation revealed that the drain port of the reverse osmosis machine was connected to the dialysis machine and the product water was connected to the drain leading to acute hypercalcemia.

Yikes! My unit sends techs to the house to bring the machine in and connect everything. They test the water before and after the RO to make sure it's cleaning properly. But your point is well taken, and appreciated. Anyone can make a mistake and it pays to double check what the techs do to make sure they got it right. Thanks for that heads up!