Latest Symptom - Low Blood Pressure

[slipkid]

Re: Low Blood Pressure

Battled drop in BP – from high to low during dialysis -- for 6 years -- typically occurring near end of dialysis session.  Systolic would drop to about 80 mmHg.  Diastolic followed downward in normal function.  Started to gain weight.  Sometimes cramping and syncope at end.  Generally not serious enough to stop UF for more than 15 minutes.  Appeared the problem was fluid overload due to poor compliance with fluid limits. 

Currently, the head nurse believes the problem with BP is my heart, and I am scheduled for another cardiac stress test – what that may reveal, that I do not already know, is unknown.  CYA?

Discussed sodium modeling with Neph, he says everyone in clinic get the same protocol!  Why?

I am gaining weight.  Was 89 kg 3 months ago, now 94.5.  I believe I am not removing enough fluid because of BP drop which precipitates discontinuation of UF.

Any thoughts?

[Worthy1]

The kidney machine doesn't know it's hooked up to a person and it is prepared by the operator to take you to your dry weight.  Rather than turn off the ultrafiltration 3 hours in perhaps you can ask about Ultrafiltration Profiling instead of sodium profiling.  UF profiling is available on Fresenius machines, there are four different profiles preprogramed into the machine.  They are similar to Sodium Profiling in the respect that you pull harder in the beginning of the treatment and not as much at the end when bp isn't as available.  You will still get dry just in a different stepwise fashon.  The idea is that you never should pull faster than your vascular system can refill.  Also remember that Dry weight is a fluid number and the estimation of which is the art of dialysis. Dialysis should never hurt. Almost all of the life changing adverse events that can happen in dialysis are a result of pulling you too dry.  Know the signs and preempt the adverse consequences.  I wish you well with your cardiac tests.   Remember to limiit your fluid intake between treatments because it is easier on your heart also don't eat food during the last hour of dialysis (blood goes to gut to digest food and is less available for your extremities)  Good Luck

[slipkid]

Thanks for your kind wish.  I did not know that fluid removal could be done in a non-linear fashion.  Will bring it up before tomorrow's session. 

[slipkid]

Have had two sessions with a downward ramp function for fluid removal.  BP has been good... no alarms. Yeah!

Thanks for your help.  You have provided a solution that has been a problem for SIX years.

[amanda100wilson]

If there is such a simple solution, WHY do the dialysis staff no know it??! 

[MommyChick]

If there is such a simple solution, WHY do the dialysis staff no know it??! 

Sorry you had to be dealing with that for so long! They should be trained to know that because not everyone is the same in dialysis. I know they have been having to put me on a special profile recently due to my BP always being low. The nurse picked up on that right away which I was happy about as well as my doctor finally started to stop some of my BP meds. as of Wednesday. So between the two I'm hoping things go well for me at dialysis today.
Its never fun when your BP drops because then I don't know about you but I always feel so drained the rest of the day.

Good Luck!!
~ Marna

[slipkid]

I don't know why I had to suggest a solution for the BP problem.  As I mentioned in my opening post, I had to negotiate a different reduction in Hectoral than their "protocol" suggested.  I got blood test results on PTH yesterday and surprise, my PTH was 10% higher from prior level.  PTH is now in the middle of the suggested range.  So my instinct that a 30% reduction in Hectoral was spot-on.

I think the staff is indoctrinated by "protocol" procedure.  I have noted that prior to dailysis, my monthly meetings with the neph doc were significantly more thorough than I get in-center.  I really wonder how much time he spends on my case every month for the $900 he bills Medicare and my insurance for servcies.

I have been reading this forum for some time, but have only recently taken the advice offered and taken control of my therapy.

Hurray for IHD!

[lmunchkin]

Sorry youve been dealing with this for sooooo  long.  Glad you are taking control of your care.  Maybe you should try doing D at home.  Lots of people are doing it and have had great sucess!  I know we are glad we did it.

Stay on top of things Slipkid and let us know how things are going.

God Bless,
lmunchkin

[MommyChick]

If there is such a simple solution, WHY do the dialysis staff no know it??! 

Sorry you had to be dealing with that for so long! They should be trained to know that because not everyone is the same in dialysis. I know they have been having to put me on a special profile recently due to my BP always being low. The nurse picked up on that right away which I was happy about as well as my doctor finally started to stop some of my BP meds. as of Wednesday. So between the two I'm hoping things go well for me at dialysis today.
Its never fun when your BP drops because then I don't know about you but I always feel so drained the rest of the day.

Good Luck!!
~ Marna

Who knows ?? I like your idea of smacking them on there head, LOL

[Desert Dancer]

I have been reading this forum for some time, but have only recently taken the advice offered and taken control of my therapy.
Hurray for IHD!

Good for you, slipkid!   

It's advice you'll never regret. You'll be surprised at how much there is to be challenged. 

[talker]

The kidney machine doesn't know it's hooked up to a person and it is prepared by the operator to take you to your dry weight.  Rather than turn off the ultrafiltration 3 hours in perhaps you can ask about Ultrafiltration Profiling instead of sodium profiling.  UF profiling is available on Fresenius machines, there are four different profiles preprogramed into the machine.  They are similar to Sodium Profiling in the respect that you pull harder in the beginning of the treatment and not as much at the end when bp isn't as available.  You will still get dry just in a different stepwise fashon.  The idea is that you never should pull faster than your vascular system can refill.  Also remember that Dry weight is a fluid number and the estimation of which is the art of dialysis. Dialysis should never hurt. Almost all of the life changing adverse events that can happen in dialysis are a result of pulling you too dry.  Know the signs and preempt the adverse consequences.  I wish you well with your cardiac tests.   Remember to limiit your fluid intake between treatments because it is easier on your heart also don't eat food during the last hour of dialysis (blood goes to gut to digest food and is less available for your extremities)  Good Luck

Have been reading the many posts here in the forum regards Low Blood Pressure .
Am experiencing some Low Blood Pressure events.
Great post here on 'what else one may need to check'.

[slipkid]

Still dealing with low BP since my OP.  Neph says its normal for a 180 degree switch during D, but offers no explanation for it, even though he has 50 years experience.  Go figure.

Since switching to home hemo 20 months ago, I have removed 25 pounds of water weight, so I have definitive evidence that the nurses in-clinic were really screwing me up.

I hope your situation has not mirrored my experience.

[Sugarlump]

I suffer from low bp on dialysis (86/40 today) and it restricts how much I can remove in a session.
I am on blood pressure tablets at night and now take less the night before dialysis to help (as I have dialysis at 7.30am)
But sodium profiling and eating a packet of crisps about halfway through helps.
I am currently also having problems with low glucose levels post dialysis... but they seem to think 1mmol glucose in dialysate bottle is okay for everyone!!!
   

[Hemodoc]

There is only one safe way to deal with low blood pressure during dialysis. First, understand WHY low BP occurs. It happens by pulling fluid from the vascular space faster than the excess fluid in the "interstitial" or third space we commonly call edema is able to refill the vascular space.

The ONLY manner in which to prevent the low BP is to remove the fluid more frequenty or at a slower rate or both.

Otherwise, you will enter a complex spiral leading to damage to your heart which in the end will increase your risk of premature death. All of the "usual" methods to control low BP actually over time will make it worse and cause irreparable damage to your heart.

Thus, longer and slower dialysis is the ONLY answer to this issue.  Here is an excellent set of articles by Dr. John Agar, an Australian nephrologist who has tried for over 10 years to teach the US renal community some common sense in dialysis. The American methods will lead to to heart damage and death. Please read the following articles from Home Dialysis Central.

http://homedialysis.org/news-and-research/blog/tags/waterfall

[talker]

I suffer from low bp on dialysis (86/40 today) and it restricts how much I can remove in a session.
I am on blood pressure tablets at night and now take less the night before dialysis to help (as I have dialysis at 7.30am)
But sodium profiling and eating a packet of crisps about halfway through helps.
I am currently also having problems with low glucose levels post dialysis... but they seem to think 1mmol glucose in dialysate bottle is okay for everyone!!!
   

Just a thought , but have you seen this:

http://ihatedialysis.com/forum/index.php?topic=31461.msg486278#msg486278

[talker]

There is only one safe way to deal with low blood pressure during dialysis. First, understand WHY low BP occurs. It happens by pulling fluid from the vascular space faster than the excess fluid in the "interstitial" or third space we commonly call edema is able to refill the vascular space.

The ONLY manner in which to prevent the low BP is to remove the fluid more frequently or at a slower rate or both.

Otherwise, you will enter a complex spiral leading to damage to your heart which in the end will increase your risk of premature death. All of the "usual" methods to control low BP actually over time will make it worse and cause irreparable damage to your heart.

Thus, longer and slower dialysis is the ONLY answer to this issue.  Here is an excellent set of articles by Dr. John Agar, an Australian nephrologist who has tried for over 10 years to teach the US renal community some common sense in dialysis. The American methods will lead to to heart damage and death. Please read the following articles from Home Dialysis Central.

http://homedialysis.org/news-and-research/blog/tags/waterfall

Went to the links you posted here. Very good write. Left a comment , but don't look like it took.

Regardless, and now am even more curious about the whole process of dialysis, AND low blood pressure events.
Will try to capture my thoughts that may not show on the site you wrote your article on.

Am aware that ones blood is the main line of transport to and from each and every cell within ones body.
Nourishment, plus oxygen in, and waste material out for each and every cell in the body.
Do I understand your very meaningful write to mean, that the exchange of goods/waste, occur at different times!
This differential in time, is what create a vacuum so to speak, that lessons the blood volume!
Which in turn partially contributes to low blood pressure!
Which further requires a 'lull' before some degree of homeostasis occurs within each cell !

Not wanting to be a doctor, nor pretending to be a doctor, just wanting to avoid that low blood pressure event while on dialysis.
So am just wanting to better understand and 'do' what is best for this ancient body of mine.

So in your 'opinion'  what would you say about the ultrafiltration profile, phase 1, that I'm now on, that I had inquired about in my post!

Not asking for a diagnosis, only for your 'thoughts' on what I inquire about.
Thank you

[Hemodoc]

There is only one safe way to deal with low blood pressure during dialysis. First, understand WHY low BP occurs. It happens by pulling fluid from the vascular space faster than the excess fluid in the "interstitial" or third space we commonly call edema is able to refill the vascular space.

The ONLY manner in which to prevent the low BP is to remove the fluid more frequently or at a slower rate or both.

Otherwise, you will enter a complex spiral leading to damage to your heart which in the end will increase your risk of premature death. All of the "usual" methods to control low BP actually over time will make it worse and cause irreparable damage to your heart.

Thus, longer and slower dialysis is the ONLY answer to this issue.  Here is an excellent set of articles by Dr. John Agar, an Australian nephrologist who has tried for over 10 years to teach the US renal community some common sense in dialysis. The American methods will lead to to heart damage and death. Please read the following articles from Home Dialysis Central.

http://homedialysis.org/news-and-research/blog/tags/waterfall

Went to the links you posted here. Very good write. Left a comment , but don't look like it took.

Regardless, and now am even more curious about the whole process of dialysis, AND low blood pressure events.
Will try to capture my thoughts that may not show on the site you wrote your article on.

Am aware that ones blood is the main line of transport to and from each and every cell within ones body.
Nourishment, plus oxygen in, and waste material out for each and every cell in the body.
Do I understand your very meaningful write to mean, that the exchange of goods/waste, occur at different times!
This differential in time, is what create a vacuum so to speak, that lessons the blood volume!
Which in turn partially contributes to low blood pressure!
Which further requires a 'lull' before some degree of homeostasis occurs within each cell !

Not wanting to be a doctor, nor pretending to be a doctor, just wanting to avoid that low blood pressure event while on dialysis.
So am just wanting to better understand and 'do' what is best for this ancient body of mine.

So in your 'opinion'  what would you say about the ultrafiltration profile, phase 1, that I'm now on, that I had inquired about in my post!

Not asking for a diagnosis, only for your 'thoughts' on what I inquire about.
Thank you

Dear Talker,

I can't really comment on your current profile not knowing any particulars about your case, but just in general, America runs too infrequently, too fast and not long enough.  That leads to the common symptoms of cramping, nausea, vomiting and yes, low blood pressure. They are all inter-related to taking off too much fluid from the vascular compartment before the "3rd" space fluids return to the vascular compartment. That leads to damage to the heart with each session.

There are two aspects of dialysis to answer the other issue. Taking off fluids, ultrafiltration, and removing toxins done through the artificial kidney.

Longer and more frequent treatments help in both aspects. If you slow down the ultrafiltration rate so that it is equal or close to the capillary refill rate of edematous fluids, then you don't get the problems with low blood pressure commonly seen in the American units. This can be accomplished by more frequent sessions, at least every other day, or daily dialysis usually seen at home. Also, you can accomplish this by longer thrice weekly sessions now fairly available in nocturnal units. This is actually how dialysis started in the US, 6-8 hour nocturnal dialysis at home.

I would advise you to read through Dr. Agar's articles and you can visit his website which I believe is Nocturnal Dialysis. I will look up the URL for you.

I do fear if they are using sodium modeling on you, that you will end up in the cycle of sodium modeling giving you a salt load which increases your weight gains between sessions meaning they will increase your ultrafiltration rates leading to more episodes of low blood pressure. It is perhaps the most common way in which American dialysis patients die from our treatments.

There is a large body of literature on this issue that is largely, well almost completely ignored by the American nephrology community. If you have further questions, I will do my best to find you the information you need.

Take care, and I hope you are able to find a better situation and avoid further episodes of low blood pressure. Simply increasing the length of your sessions and slowing down the rate of ultrafiltration will likely offer a better resolution.

[talker]

There are two basic profiles, and a 'normal/standard' ultrafiltration, that can be setup.
1 Ultrafiltration profiling
2 Sodium profiling.
3 'normal/standard' ultrafiltration

Each of the methods listed, have their place, for specific purposes.
I chose the Ultrafiltration profiling , as I did not want to leave the dialysis center, maybe weighing more then when I initially weighed in, that a  Sodium profiling would produce.

For me, at this time, Ultrafiltration profiling appears to be working for me.      
    No low blood pressure events.

I am saying that the 'normal/standard' ultrafiltration dialysis stared giving low blood pressure events on a regular basis.
The Ultrafiltration profiling dialysis, are NOT giving any low blood pressure events .

[Hemodoc]

There are two basic profiles, and a 'normal/standard' ultrafiltration, that can be setup.
1 Ultrafiltration profiling
2 Sodium profiling.
3 'normal/standard' ultrafiltration

Each of the methods listed, have their place, for specific purposes.
I chose the Ultrafiltration profiling , as I did not want to leave the dialysis center, maybe weighing more then when I initially weighed in, that a  Sodium profiling would produce.

For me, at this time, Ultrafiltration profiling appears to be working for me.      
    No low blood pressure events.

I am saying that the 'normal/standard' ultrafiltration dialysis stared giving low blood pressure events on a regular basis.
The Ultrafiltration profiling dialysis, are NOT giving any low blood pressure events .

Yes, ultrafiltration profiles do help some patients. However, if you want to have a clear understanding of WHY folks become hypotensive, or low blood pressure, then you have to look at the physiology of what is going on to cause these events. I am glad that ultrafiltration profiling helps at this time. It may not in the future.

Once again, I have gone over the physiology of what causes these events in the majority of dialysis patients. I hope that information is useful. Lastly, you have listed SOME of the many strategies for dealing with low blood pressures in the dialysis unit. However, the only strategies that address the underlying physiologic reason for these events is to increase frequency or duration AND lower ultrafiltration rates. That is the definitive strategy.

Good luck and I hope you are able to find a suitable strategy in the long term.  Take care.

[komomai]

When I experience low BP, I can feel it before it gets too serious.  I just ask the nurse what my BP is and tell them to drop the water removal and if needed dump saline into me.  Since I'm trying for home hemodialysis we prime our own machine, the nurse checks it, we put in the heperin set the levels according to the Doctors.  Then I look at my dry weight and figure out what I want for a target weight then I discuss it with the nurse and they will tell me if it's to much.  I try for a water draw of 800 ml/hr.  I do dialysis M-F for 3 hours a session.  The good news is that I will be doing home hemodialysis in Oct.  Note I still have a tunnel catheter in my left leg, I just don't have any more annual/sick leave to do the fistula operation.  Hopefully by next year, I'll have enough to do the fistula.  Oh yeah when I started I weighed in at 110 kg. now I'm down to 78 kg and feeling fine.  Aloha.

[Sugarlump]

There is only one safe way to deal with low blood pressure during dialysis. First, understand WHY low BP occurs. It happens by pulling fluid from the vascular space faster than the excess fluid in the "interstitial" or third space we commonly call edema is able to refill the vascular space.

The ONLY manner in which to prevent the low BP is to remove the fluid more frequently or at a slower rate or both.

Otherwise, you will enter a complex spiral leading to damage to your heart which in the end will increase your risk of premature death. All of the "usual" methods to control low BP actually over time will make it worse and cause irreparable damage to your heart.

Thus, longer and slower dialysis is the ONLY answer to this issue.  Here is an excellent set of articles by Dr. John Agar, an Australian nephrologist who has tried for over 10 years to teach the US renal community some common sense in dialysis. The American methods will lead to to heart damage and death. Please read the following articles from Home Dialysis Central.

http://homedialysis.org/news-and-research/blog/tags/waterfall

Went to the links you posted here. Very good write. Left a comment , but don't look like it took.

Regardless, and now am even more curious about the whole process of dialysis, AND low blood pressure events.
Will try to capture my thoughts that may not show on the site you wrote your article on.

Am aware that ones blood is the main line of transport to and from each and every cell within ones body.
Nourishment, plus oxygen in, and waste material out for each and every cell in the body.
Do I understand your very meaningful write to mean, that the exchange of goods/waste, occur at different times!
This differential in time, is what create a vacuum so to speak, that lessons the blood volume!
Which in turn partially contributes to low blood pressure!
Which further requires a 'lull' before some degree of homeostasis occurs within each cell !

Not wanting to be a doctor, nor pretending to be a doctor, just wanting to avoid that low blood pressure event while on dialysis.
So am just wanting to better understand and 'do' what is best for this ancient body of mine.

So in your 'opinion'  what would you say about the ultrafiltration profile, phase 1, that I'm now on, that I had inquired about in my post!

Not asking for a diagnosis, only for your 'thoughts' on what I inquire about.
Thank you

Dear Talker,

I can't really comment on your current profile not knowing any particulars about your case, but just in general, America runs too infrequently, too fast and not long enough.  That leads to the common symptoms of cramping, nausea, vomiting and yes, low blood pressure. They are all inter-related to taking off too much fluid from the vascular compartment before the "3rd" space fluids return to the vascular compartment. That leads to damage to the heart with each session.

There are two aspects of dialysis to answer the other issue. Taking off fluids, ultrafiltration, and removing toxins done through the artificial kidney.

Longer and more frequent treatments help in both aspects. If you slow down the ultrafiltration rate so that it is equal or close to the capillary refill rate of edematous fluids, then you don't get the problems with low blood pressure commonly seen in the American units. This can be accomplished by more frequent sessions, at least every other day, or daily dialysis usually seen at home. Also, you can accomplish this by longer thrice weekly sessions now fairly available in nocturnal units. This is actually how dialysis started in the US, 6-8 hour nocturnal dialysis at home.

I would advise you to read through Dr. Agar's articles and you can visit his website which I believe is Nocturnal Dialysis. I will look up the URL for you.

I do fear if they are using sodium modeling on you, that you will end up in the cycle of sodium modeling giving you a salt load which increases your weight gains between sessions meaning they will increase your ultrafiltration rates leading to more episodes of low blood pressure. It is perhaps the most common way in which American dialysis patients die from our treatments.

There is a large body of literature on this issue that is largely, well almost completely ignored by the American nephrology community. If you have further questions, I will do my best to find you the information you need.

Take care, and I hope you are able to find a better situation and avoid further episodes of low blood pressure. Simply increasing the length of your sessions and slowing down the rate of ultrafiltration will likely offer a better resolution.

I am interested go know why sodium profiling increases weight gain between treatments?
Is this solely because of increased thirst and fluid gain or actual weight gain?

[Hemodoc]

Sodium modeling adds salt to the patient. Fluids follow the salt.