Thank you NxStage

[obsidianom]

My wife has been using Nxstage for about a year now. She was in center originally about 2 months and HATED it. NxStage has saved her life and made our lives better. She dialyses 5 times per week for about 2 and 3/4 hours per treatment.  That gives her about  3.5 hours more time weekly on dialysis than in center which is MUCH better for her. She actually prefers dialysis days to days off as she feels much better after diaylsis.
Nxstage is great to work with . Any time I need help or have a problem I call and the Techs are great on the phone to help with anything. They just replaced our cycler after 1 year as it had a keypad issue . The new machine arrived by currier the NEXT DAY.  The pureflow system is great as it uses so little water and is easy to use. I spend more time talking with the Nxstage people than the nurses at the clinic as they handle everything so well. I recommend this system to anyone doing home hemo dialysis and for those who are in center  who are thinking of going home . It really is better for my wife than the other type machines .

[Speedy1wrc]

I'm glad you have had good luck with NxStage. unfortunately I havent . In a year I am on my 6th cycler and 3rd or 4th PureFlow. I have an abysmally high failure rate on cartridges and am in the middle of a long standing air issue as we speak.

I am seriously thinking about going back in center since it literally consumes my entire day dealing with either rdialysis or other related issues. I need my life back.

[Hemodoc]

I'm glad you have had good luck with NxStage. unfortunately I havent . In a year I am on my 6th cycler and 3rd or 4th PureFlow. I have an abysmally high failure rate on cartridges and am in the middle of a long standing air issue as we speak.

I am seriously thinking about going back in center since it literally consumes my entire day dealing with either rdialysis or other related issues. I need my life back.

That sounds quite unusual. Have you discussed these issues with your clinic. I just traded in a machine with a "71" alarm which meant it was time for maintenance .  My experience is not as you are describing.

[obsidianom]

I second what Hemodoc wrote. I have had only 1 replacement in over a year and a half. They made it quick and easy to replace the cycler for maintenance. AS it is so portable , a new one came via car and we had it up and running in 5 minutes. Pureflow works smoothly .
Not to jinx myself, but we never get alarms these days. I guess its been months since I saw a single alarm. I found when it used to alarm it was something I did wrong. AS I learned all the nuances and litttle tricks it has become routine now. I work out on my treadmill while my wife is on the cycler. I hardly know it is running. She ignores it completely . 

[russ9320]

I haven't had too many issues with my nxstage machine. Most of my issues are access.related. you said.you get a bunch of air alarms. The only time I get an air alarm is 11. That is caused by me moving my arm and causing the arterial access pressure to skyrocket. That temporarily pulls air from the pressure pod and the sensor is just pass the pressure pod.

[obsidianom]

One thing you can do to reduce air in the pressure pod and in the whole system is to clamp the red clamp during the snap and tap or just before it while it is at "23".  Clamp it for 3 or 4 seconds then open it. This pushes air out quickly and hard. If you do it 3 times it seems to really reduce air in the pod and line . Since doing this I have never had an air alarm again.

[russ9320]

There is always going to be air in the pod. If not then your arterial pressure is too high. The only reasons I get an alarm is when I move my arm and the needle sucks to the wall.

[obsidianom]

Our arterial pressure runs at 90 or less usually with a blood flow of 340. We use short needles(5/8 inch) which greatly reduces the chances of the needle banging the wall. Longer needdles end up being the issue often.

[Hemodoc]

One thing you can do to reduce air in the pressure pod and in the whole system is to clamp the red clamp during the snap and tap or just before it while it is at "23".  Clamp it for 3 or 4 seconds then open it. This pushes air out quickly and hard. If you do it 3 times it seems to really reduce air in the pod and line . Since doing this I have never had an air alarm again.

Dear obsidianom, I would have to wonder if that would actually increase air in the system by cavitation. I have accidently clipped the red and turned it on and then I have to spend several minutes getting rid of the air created by doing that especially while I am doing my rinse.

I have found that setting the machine up, then going and doing my supplies and take a shower, in that time, the micro-bubbles aggregate into larger macro-bubbles that I can easily snap and tap. I then draw my heparin and pick my scabs and then when every thing is ready, I do a final snap and tap. Well actually a series of snap and taps and I tap the pressure pod itself.

The other thing I do is to snap and tap the white line after I hook up the white to white. If you do this, there is very little air bubbles left when you do your rinseback.

[russ9320]

Yeah that all would work. I use 1 inch needles and blood flow rate is 450. At 350 I'd be on for 6 hours. I have 30 litres of dialysate and an ff of 40. Andto add to an answer to another question you asked me, I am 6'T3'' and my dry weight is 120.5 KG. Using bags is not that inconvenient to me... like a mini workout.

[obsidianom]

One thing you can do to reduce air in the pressure pod and in the whole system is to clamp the red clamp during the snap and tap or just before it while it is at "23".  Clamp it for 3 or 4 seconds then open it. This pushes air out quickly and hard. If you do it 3 times it seems to really reduce air in the pod and line . Since doing this I have never had an air alarm again.

Dear obsidianom, I would have to wonder if that would actually increase air in the system by cavitation. I have accidently clipped the red and turned it on and then I have to spend several minutes getting rid of the air created by doing that especially while I am doing my rinse.

I have found that setting the machine up, then going and doing my supplies and take a shower, in that time, the micro-bubbles aggregate into larger macro-bubbles that I can easily snap and tap. I then draw my heparin and pick my scabs and then when every thing is ready, I do a final snap and tap. Well actually a series of snap and taps and I tap the pressure pod itself.

The other thing I do is to snap and tap the white line after I hook up the white to white. If you do this, there is very little air bubbles left when you do your rinseback.

Peter, actually it works quite well. I have used this approach for months and see all the air come out when I do this. I havent had a single air alarm since I started this. I know others who do it also and claim the same sucess. Try it. It clears the saline line as well as the blood lines.

[obsidianom]

Yeah that all would work. I use 1 inch needles and blood flow rate is 450. At 350 I'd be on for 6 hours. I have 30 litres of dialysate and an ff of 40. Andto add to an answer to another question you asked me, I am 6'T3'' and my dry weight is 120.5 KG. Using bags is not that inconvenient to me... like a mini workout.

Your blood flow speed is very high and can and may have actually damaged your fistula.  Dr. John Agar in Australia cant iamgine ever running a patient at over 340 blood speed. he prefers down around 220 . I run ours at 340. Speed over 350 can stun the heart , and damage the fistula . In Australia they rarely see the damage we see in fistulas here in the US at our higher speeds. 450 is a killer speed.
You can turn your FF way up and run the dialysate speed at 10 liters per hour and get 3 hour treatment at 30 liters. that is exactly what we do . Our FF runs about 50%. We run the blood at 340. That gets us 63 liters of blood cleared. You are running your FF too slow.
Now the other issue is your total volume of dialysate. You are running 30 liters. My wife who weighs 52 kg and is 5ft2 inch uses 30 liters , 5 days per week. With your size you should really be at closer to 40 to 50 liters. Have your nephrologist run the numbers for you on the on line calculator. You might feel better on more dialysate.  You could run 40 liters at max. speed of 12 liters per hour and that would take 3 houres 20 min.  . At 50 liters and 12 liters per hour it would be just over 4 hours.   Nxstage had patients on too low a dialysate in the past and now it appears they are upping it based on the on line calculator. We started at 20 liters which wasnt enough and at 30 my wife feels a lot better.
If you have questions, ask .

[russ9320]

I started with a ff of 44 and 25 liters of dialysate. My kt/v was under 2. That is why my ff went down and my liters went up.

[obsidianom]

Actually the FF is an artificially created number for Nxstage that has little effect on dialysis. It is the volume that matters. Volume of dialysate and then to a lesser degree volume of blood. When you increased to 30 liters you increased volume that is why the numbers changed. As you increase the volume of dialysate you increase clearances. That is why you need more. You are still running low at 30 liters.

[russ9320]

That is true but lowering the FF causes you to process more blood. The problem with increasing volume is the warmer lines only fit 45 liters.

[obsidianom]

45 liters is a lot more than 30, 50% more.   You should have your nephrologist run your numbers on the on line calculator and you and he/she will see what volume you really need. I ran numbers on a generic patient about your size and it came out between 40 and 50 liters. Blood volume is a lot less important on Nxstage then dialysate volume.   

[obsidianom]

WE just got our numbers from the last blood draw. My wifes URR( urea reduction ratio) was  64% . That is with the new 30 liter treatments. We used to be at 20. It is higher than it used to be . She used to get 55% or less.  So increasing the dialysate from 20 to 30  has at least shown up on the blood tests. I realize that URR is not that important in reality but it is all we have.  It shows with her at least NxStage is doing a good job .

[obsidianom]

This next paragraph was part of a recent journal article on more frequent dilaysis (5 to 7 days per week) like Nxstage. The whole article discussed many advantages, but cardio-vascular were the most important.

'Registry-based data are suggestive that daily HD may be associated with CV mortality rates superior to conventional therapy [7–9] and akin to those seen in patients receiving cadaveric renal transplantation.'

So another point for Nxstage daily dialysis.

[Simon Dog]

Met with my doc yesterday.  My care partner evicted the Baby K (sick of the alarms, me passing out on occasion, etc.) so I am switching to NxStage,  training starts next Monday.     It's expected to be one week in clinic then one week at my house.

[obsidianom]

Best of luck. I am sure it will be an easy transition. If you have any questions , ask here any time.
My wifes clinic nurse just reported our latest numbers were a KT/v of 3.08 which interestinly enough is almost exactly what Nxstage predicted with our prescription. I was looking at 3 or better and got it.  Nice to see what they predict, does in fact work.

[amanda100wilson]

 Russ9323, at your height, I would think that you would need a higher volume of dialysate, 30 liters for your height seems pretty low.  I also wonder if the the S model of the NxStage machine would be a more appropriate option for you?  You may want to ask your doc. And NxStage nurse.  Definately sounds as if they need to use the NxStage Dose Calcalator to determine your needs.

[obsidianom]

Another interesting Nxstage story.
Our dialysis home nurse was telling us todya about the 2 new patients in our area using Nxstage after being in center for awhile. They are now over 3 months on Nxstage. One treats 5 days per week , the other 6 days. Both report feeling MUCH better with Nxstage then in center standard dialysis.
The other interesting fact is each reports the same finding my wife does. They feel BETTER during and AFTER dialysis with Nxstage as opposed to how bad they felt with standard dialyisis . In fact the 6 day patient asked if he could go to 7 days as he hates missing a day , as he feels so good after.
So that is 3 patients in our small area all on Nxstage and all 3 reporting similar stories of how much better they feel and prefer Nxstage to conventional dialysis. No one has yet had a negative experience with nxstage.
We were the first here to use it and now the nurses and doctors are beginning to come around to seeing it as positive. Initially they were very negative before we started back in June of 2012.
I wish every dialysis patient could just TRY NxStage for a week or 2 and see how they felt. It might change a lot of the negativity about dialysis. Yes its a lot of work , but if you can feel better its worth it.

[Speedy1wrc]

Sorry, been busy for awhile. Haven't been on here in quite some time.

My HHD nurse has been the one keeping me sane. Whether it be problems with Nxstage or Sterling, it's not just a job, it's an adventure. The quality of the machine is more dependent on DaVita than NxStage. In our area, when you get a machine it comes from a refurbishment center and they are sketchy at best. I have gotten machines which have clearly been dropped, shipped without packaging, never cleaned or sterilized, you get the idea. At best a machine in this neck of the woods will last a year. It's not uncommon to hear that we all have a batch of failures all at the same time. Every area and center has it's own issues. Ours is with equipment. Our HHD nurse is the best by far. That's my story and I'm sticking to it!

NxStage has gotten better, but there is still an ongoing issue with air which is a design and implementation issue. I'll cover that in a separate post. As I write this I just finished firing off an email to one of their senior tech's requesting another cycler. The dialysate stepper motor is making a lot of noise. It's more noticeable since I developed a new set of parameters to prime which is much better at removing air, but alas it highlights any deficiencies in the motors since it tends to raise the torque values, but I digress. I just also got my 4th Express Warmer in just over a year. Again, not a great track record, especially since it only gets used rarely.

Russ, you are not pulling air from the pressure, pod, or at least you better not be. I think it was hemodoc who got it, you are cavitating your access, which is not a good thing.

Obsidianom, I have heard that method for clearing air. While it gets rids of the current air, make sure that you are getting rid of all the air. As the saline de-gasses it will release even more air. Too many people do a quick S&T and if they don't see air, onward they go. Getting rid of dissolved air is also very important. To see if you have dissolved air, let it run for about 15 mi and check for air again. If you see the bubbles come back, you still haven't gotten rid of it all just yet. It sounds like you already let it run for awhile, so it may not be an issue.

Hemodoc, you scare me when you say there are "few" bubbles left. There should be zero, none. While the mantra is that micro-bubbles are ok since they won't cause emboli, they are actually detrimental to long term health. When a micro-bubbles(read microscopic) burst, the tissue next to where they have resided, dimples. While this is generally ok for intermittent occurrences in small quantities, large quantities as a hemo patient might see can cause cumulative damage. The tissue damage can be vascular, pulmonary or even cerebral. This is damage that would accrue over say 10-15 years. Studies recommend the use of de-gassers on hemodialysis machines. Get the air out! I have been working for several months now to develop a prime sequence which will keep as much air as possible out of the saline. On top of that a decent amount of recirculation prior to S&T will ensure a minimal amount of air/micro-bubbles in the lines. I'm waiting for results of a secondary test to validate what I have come up with and then I will publish my results.

I haven't read the studies on blood flow yet (I will), but from an engineering viewpoint if your heart is pumping at a rate of nearly 6L/min the difference between 300 or so ml/min and 500 ml/min doesn't seem significant. I promise I will go read the studies for myself. I run at 500 ml/min and it works for me. I get to process close to 90L over just about 3hrs with 30L of dialysate. I'm achieving a clearance of 2.39. However my URR is a bit lower than I'd like. At one point I was around 48. I am higher now, but I can't find the latest lab results. Darn paper mess...

On the plus side, after a little over a year on Home Hemo I am almost completely off BP med's. Fistula aside, that's an awesome accomplishment. I am still tapering the last of my med's and of course I am getting a transplant soon (fingers always crossed), but anticipate being off them hopefully sooner than later. There is always good with the bad.

[Hemodoc]

Dear Speedy1wrc,  I am not sure if you feel in your reply that I am ADVOCATING leaving the remaining micro-bubbles in since it appears you are chiding me a bit. Not at all my friend. I am simply noting the reality that no matter how carefully you snap and tap and employ recirculation or other methods, you cannot remove all of the bubbles. I spend about 15-20 minutes removing as many as I can. Data shows you can remove over 75% of the bubbles with careful attention, but without bubble traps, you cannot remove them all. To date, we have no commercially available bubble traps but many have been developed and ignored by American dialysis companies. So, I am not at all cavalier about micro-bubbles as you appear to imply. When hooking up, it is almost impossible to not get air in the line and cavitation from high pump speeds develops micro-bubbles during dialysis as well. It is what we live with and is one of the least talked about dangers of dialysis.  http://www.ncbi.nlm.nih.gov/pubmed/22236622

[Speedy1wrc]

Sorry, I took your comment at face value where you said "few bubbles...". indeed all I hear from NxStage educators and tech support is a few air bubbles are OK. I get tired of it sometimes. With the issues I have been having it's a pet peeve that no one seems to want to address. NxStages official policy as I have been told is that micro-bubbles are ok. I have had an educator look at the bubbles in my lines and shrug their shoulders and say it looks fine. Reading many forum posts I can tell other patients have been told the same thing.

You hit the nail on the head. The high speeds attribute to the amount of air in the system. I've been working on prime settings which slow the whole process down and eliminates a very large amount of the air during dialyze flush. At the point where the dialyzer is being flushed all the pumps start rip roaring away and as I'm sure you've seen there develops a pretty good head in the saline bag. That along with stating with warm saline so far has worked out pretty well in keeping bubbles from forming in the first place. Unfortunately the last few days I've been inundated with bubbles due to a faulty motor. Slight set back.

Changing the prime parameters and recirculating for about 30 tends to leave the lines pretty clear. At least to an unassisted eye. The saline bag which used to be pretty cloudy is now clear. I'm having someone else try it and see what their opinion is. Keep you posted.

Sorry if I took it the wrong way.