Shotgun Dialysis vs. Healthy Dialysis

[Zach]

The  following is from Home Dialyzors United (formerly NxStage Users Group):
http://homedialyzorsunited.org/hennings-corner-world-shotgun-dialysis-vs-healthy-dialysis/

Henning’s Corner of the World: Shotgun Dialysis vs. Healthy Dialysis

Here in Denmark where I live (most of the time and officially) many, if not all, doctors dealing with dialysis say that the NxStage machine doesn’t ‘clean as well’ as other machines on the market. That is a truth with modification, to say the least. I am convinced that this statement is something that was created by and continues to be perpetuated by representatives from other companies, like Fresenius and Baxter. However, I also think there is something to it if one views it in a certain light.

In the US there is an entirely different problem that I want to address. I read about many patients who are running at what I would term ridiculous blood flow rates. A rate of 400-500 is not uncommon. To me, those sorts of speeds are rife with problems. No wonder problems like stenosis and thrombosis seem so much more prevalent here than in other parts of the World.

You might ask what these two things have in common. On the surface apparently nothing. But in reality they are signs of an insidious underlying problem. Then again it’s not really a problem as such. It’s a matter of understanding and acknowledging the simple truth that dialysis takes time.

This basic fact is something that all doctors know and willingly talk about when asked. Articles abound in the field about time needed for effective dialysis. Nephrologists write in their blogs about patients needing more time. But in a completely misguided sort of ‘care’ for their patients they are often not willing to acknowledge this fact, nor do they teach it to the very patients that need this information the most.

The excuses are manifold, but most typically doctors will claim that the patients don’t want to dialyze for the time that is necessary – and of course they don’t. Who wants to do more treatment than what their doctors tell them is necessary? Not me, that’s for sure. But I will spend the extra time when I am told the truth. The truth is that I will feel better, I will be in much better health and I will live far longer when I engage in proper dialysis.

What most people are taught is shotgun dialysis. It doesn’t matter if it’s in-center or at home (at least here in Denmark, where the home hemo standard is about 3 hours 3-4 times a week – far from enough to live a healthy life). They are told that it is ‘adequate’ and in many cases it is adequate – for survival and for short term health. But it is NOT adequate to live a somewhat decent life. Shotgun dialysis is only barely enough to not end up in the hospital time and again.

It is quite logical that we as patients don’t want to spend a minute extra on the machine. But the logic breaks down when it turns out that by spending that little extra time in treatment, we get way more time at the other end. Time where we feel good and we are able to do the things we really want to do.

Unfortunately,  there is but one simple fact that determines good dialysis and therefore also determines our longevity. It is the amount of hours spent every week cleaning our blood – and don’t buy into the idea that high blood flow can decrease that time (I will get to why in a moment).

The post-treatment recovery time is just one (some might even claim, minor) problem associated with shotgun dialysis. The body can’t really get rid of its extra fluid in such a short period of time. The fluid that is removed is what is in the bloodstream but we also have a build-up of fluids inside the cells and between the cells and that fluid does not have time to enter the bloodstream during short infrequent sessions. That means the body suddenly feels dehydrated because the fluid from the bloodstream is drained. BP drops and people cramp. This feeling is a major reason people hate dialysis. However, in reality, they are not dehydrated, yet they get a saline bolus and end up over-hydrated at the end of treatment. This is VERY hard on the heart, as it has a rough time trying to keep up with high blood pressure as a result.  This is referred to as cardiac stunning.

Also, tons of toxic agents (the so-called middle molecules, amongst them phosphate, are not removed adequately by shotgun dialysis. They will slowly build up and mess with our system so we feel terrible from having these toxins in our bodies.

Back in 2002,  Belding Scribner, the ‘father’ of home hemodialysis, wrote an article along with Dimitrios Oreopoulos, the ‘father’ of peritoneal dialysis about why long gentle dialysis is better for us all[1]. In that article they do away with the idea of Kt/V. They say forget about the K (urea clearance) and focus on the t (dialysis time). The simple reason for this is that urea clearance is a really, really bad measure of adequate dialysis since urea is easily removed,  as opposed to the aforementioned middle molecules that take longer to remove. Therefore, time is of the essence here, folks!

Why is it that we are withheld such a basic truth? The two grand old men of dialysis say it very clearly in the article: “Short hemodialysis sessions have great appeal only to the uninformed dialysis patient and to for-profit dialysis centers.” And that is why there is no way in hell we can compensate for longer sessions with those ridiculous blood flow rates I keep hearing about.

That is also why my NxStage machine is equally good for treatment as any Fresenius machine. I will give them that NxStage probably does shotgun dialysis poorly and that is why is has gotten such a bad rap in my country. But it was never made for shotgun dialysis – so there.

In my opinion the 3-page article by Scribner and Oreopoulos ought to be required reading for all doctors before they are ever introduced to their first dialysis patient. Not only does the article do away with the antiquated and flawed idea of Kt/V, it replaces it with one that is much easier to work with. So easy to work with, in fact, that we patients can do it ourselves. So bear with me as I try to explain it (if I do my job properly you can even use it yourself).

They call their measure Home Dialysis Product (HDP). It is calculated thus: (hours/dialysis session) x (dialysis sessions/week)2

So let’s say I do 3 hours 6 times a week, I get 3*62 = 108

The article does not give a solid answer as to how much is enough. It talks about a critical range below 60 and with my actual schedule I end up with a number of 72 – at which I feel great. The regular in-center regime of 3-4 hrs 3 times a week gives a range of 27-36 on this scale, which obviously is far from adequate.

Like my wife wisely says: more time on the machine gives you more time in your life. You get more hours in a day because you have more energy and shorter recovery time. You get more days in a month because you will spend less time being sick and/or hospitalized. Most of all, more time on the machine adds more years to your life because your overall health will be improved. The strain on your heart and the rest of your system is significantly lessened.

This time to live is what we gain by giving up shotgun dialysis. Do you think it’s worth it?

[1] Scribner & Oreopoulos: The Hemo Dialysis Product (HDP): A Better Index of Dialysis Adequacy than Kt/V
http://onlinelibrary.wiley.com/doi/10.1002/dat.20619/full

[cdwbrooklyn]

This was a good read but like I always said, what works for one patient may not work the another patient.  I use NxStage and I love the way it makes me feel.  My clearance after treatment is 83 and I do 450 – 500 blood flow, 30L, 5 times a week for two and quarter to three hours.   I don't feel dehydrated at all after treatment.  I only feel very hungry. My blood pressure is good and sometimes it get too low where I have to eat some olives or drink fluid.   It works well for me as of now and I prayer it will many more years to come.

Just because you read it doesn't mean it's so. 


Anyhoo, good read!!! 

[talker]

The  following is from Home Dialyzors United (formerly NxStage Users Group):
http://homedialyzorsunited.org/hennings-corner-world-shotgun-dialysis-vs-healthy-dialysis/

Henning’s Corner of the World: Shotgun Dialysis vs. Healthy Dialysis

Here in Denmark where I live (most of the time and officially) many, if not all, doctors dealing with dialysis say that the NxStage machine doesn’t ‘clean as well’ as other machines on the market. That is a truth with modification, to say the least. I am convinced that this statement is something that was created by and continues to be perpetuated by representatives from other companies, like Fresenius and Baxter. However, I also think there is something to it if one views it in a certain light.

In the US there is an entirely different problem that I want to address. I read about many patients who are running at what I would term ridiculous blood flow rates. A rate of 400-500 is not uncommon. To me, those sorts of speeds are rife with problems. No wonder problems like stenosis and thrombosis seem so much more prevalent here than in other parts of the World.

You might ask what these two things have in common. On the surface apparently nothing. But in reality they are signs of an insidious underlying problem. Then again it’s not really a problem as such. It’s a matter of understanding and acknowledging the simple truth that dialysis takes time.

This basic fact is something that all doctors know and willingly talk about when asked. Articles abound in the field about time needed for effective dialysis. Nephrologists write in their blogs about patients needing more time. But in a completely misguided sort of ‘care’ for their patients they are often not willing to acknowledge this fact, nor do they teach it to the very patients that need this information the most.

The excuses are manifold, but most typically doctors will claim that the patients don’t want to dialyze for the time that is necessary – and of course they don’t. Who wants to do more treatment than what their doctors tell them is necessary? Not me, that’s for sure. But I will spend the extra time when I am told the truth. The truth is that I will feel better, I will be in much better health and I will live far longer when I engage in proper dialysis.

What most people are taught is shotgun dialysis. It doesn’t matter if it’s in-center or at home (at least here in Denmark, where the home hemo standard is about 3 hours 3-4 times a week – far from enough to live a healthy life). They are told that it is ‘adequate’ and in many cases it is adequate – for survival and for short term health. But it is NOT adequate to live a somewhat decent life. Shotgun dialysis is only barely enough to not end up in the hospital time and again.

It is quite logical that we as patients don’t want to spend a minute extra on the machine. But the logic breaks down when it turns out that by spending that little extra time in treatment, we get way more time at the other end. Time where we feel good and we are able to do the things we really want to do.

Unfortunately,  there is but one simple fact that determines good dialysis and therefore also determines our longevity. It is the amount of hours spent every week cleaning our blood – and don’t buy into the idea that high blood flow can decrease that time (I will get to why in a moment).

The post-treatment recovery time is just one (some might even claim, minor) problem associated with shotgun dialysis. The body can’t really get rid of its extra fluid in such a short period of time. The fluid that is removed is what is in the bloodstream but we also have a build-up of fluids inside the cells and between the cells and that fluid does not have time to enter the bloodstream during short infrequent sessions. That means the body suddenly feels dehydrated because the fluid from the bloodstream is drained. BP drops and people cramp. This feeling is a major reason people hate dialysis. However, in reality, they are not dehydrated, yet they get a saline bolus and end up over-hydrated at the end of treatment. This is VERY hard on the heart, as it has a rough time trying to keep up with high blood pressure as a result.  This is referred to as cardiac stunning.

Also, tons of toxic agents (the so-called middle molecules, amongst them phosphate, are not removed adequately by shotgun dialysis. They will slowly build up and mess with our system so we feel terrible from having these toxins in our bodies.

Back in 2002,  Belding Scribner, the ‘father’ of home hemodialysis, wrote an article along with Dimitrios Oreopoulos, the ‘father’ of peritoneal dialysis about why long gentle dialysis is better for us all[1]. In that article they do away with the idea of Kt/V. They say forget about the K (urea clearance) and focus on the t (dialysis time). The simple reason for this is that urea clearance is a really, really bad measure of adequate dialysis since urea is easily removed,  as opposed to the aforementioned middle molecules that take longer to remove. Therefore, time is of the essence here, folks!

Why is it that we are withheld such a basic truth? The two grand old men of dialysis say it very clearly in the article: “Short hemodialysis sessions have great appeal only to the uninformed dialysis patient and to for-profit dialysis centers.” And that is why there is no way in hell we can compensate for longer sessions with those ridiculous blood flow rates I keep hearing about.

That is also why my NxStage machine is equally good for treatment as any Fresenius machine. I will give them that NxStage probably does shotgun dialysis poorly and that is why is has gotten such a bad rap in my country. But it was never made for shotgun dialysis – so there.

In my opinion the 3-page article by Scribner and Oreopoulos ought to be required reading for all doctors before they are ever introduced to their first dialysis patient. Not only does the article do away with the antiquated and flawed idea of Kt/V, it replaces it with one that is much easier to work with. So easy to work with, in fact, that we patients can do it ourselves. So bear with me as I try to explain it (if I do my job properly you can even use it yourself).

They call their measure Home Dialysis Product (HDP). It is calculated thus: (hours/dialysis session) x (dialysis sessions/week)2

                                                                       

So let’s say I do 3 hours 6 times a week, I get 3*62 = 108

The article does not give a solid answer as to how much is enough. It talks about a critical range below 60 and with my actual schedule I end up with a number of 72 – at which I feel great. The regular in-center regime of 3-4 hrs 3 times a week gives a range of 27-36 on this scale, which obviously is far from adequate.

Like my wife wisely says: more time on the machine gives you more time in your life. You get more hours in a day because you have more energy and shorter recovery time. You get more days in a month because you will spend less time being sick and/or hospitalized. Most of all, more time on the machine adds more years to your life because your overall health will be improved. The strain on your heart and the rest of your system is significantly lessened.

This time to live is what we gain by giving up shotgun dialysis. Do you think it’s worth it?

[1] Scribner & Oreopoulos: The Hemo Dialysis Product (HDP): A Better Index of Dialysis Adequacy than Kt/V
http://onlinelibrary.wiley.com/doi/10.1002/dat.20619/full

Nice article, with relevant info regards my own dialysis sessions.
My left brain logic must have been sound asleep when I first came across this post.

At first the numbers just didn't work out ?     

So let’s say I do 3 hours 6 times a week, I get 3*62 = 108

Ah, finally came the dawn and what I had overlooked due to how it was shown.                                                      

[Charlie B53]

One of you are needed to spell out the math for me because though I conquered calculus this simple line leaves me out.

Is that '2' supposed to be a factor/square or what?   I am lost.

[Vt Big Rig]

In the example below the 6 (times per week) is squared   ...... or 36 ........ then times 3 (hours per treatment)  for 108

[caregivertech1]

Great post Zach. I'm also a true believer of "time on the machine". We were trained on the shotgun approach or as Dr. John Agar describes as "Bazooka" dialysis. My wife started at a blood rate(Qb) of 500 and only 20L of dialysis. For 2 years we were killing the fistula, stunning the heart, and never got above 2.0 on Kt/V. After many fistulagrams with a  complete revision and researching Dr. Agars work with help from this board, we now do around 17 hrs. a week vs 10. Our Qb is 340 with 30 L of dialysate. Venous pressure has dropped from a dangerously high of 280 down to 115. Arterial pressures dropped from 190 to 100. Kt/V is now above 2.6. Also my wife's heart as measured by ejection fraction is greatly improved. Also not one fistulagram needed in over a year and a half with these lower speeds and increased times. She feels absolutely great each time we come off dialysis. Look at the Nxstage dosing calculator on their web site. It clearly says using an UF rate lower than 10ml/hr/kg improves mortality. So my wife weighs 60kg and because of the slower speeds and longer dialysis we never exceed a UF rate of .6. Nxstage CAN deliver excellent dialysis.

[caregivertech1]

Calrification: exact quote from dosage calculator...."UF rates below 10ml/hr/kg improve mortality".  The slower the better.

[talker]

Nice article, with relevant info regards my own dialysis sessions.
My left brain logic must have been sound asleep when I first came across this post.

At first the numbers just didn't work out ?     

So let’s say I do 3 hours 6 times a week, I get 3*62 = 108

Ah, finally came the dawn and what I had overlooked due to how it was shown.                                                    

Here is how it should have read:

So let’s say I do 3 hours 6 times a week, I get 3*6² = 108

 
 ♫  ♫ ♫ ♪♪

Got the squared symbol using ALT 0178

Also ALT 14 and ALT 13 gave the musical notes.

Play with pressing the ALT while punching in numbers on the numerical key pad for interesting symbols.

◙  ♂ ♀ ☼ ► ◄ ↕ ░ ╞

[Vt Big Rig]

."UF rates below 10ml/hr/kg improve mortality".  The slower the better.

You mean that FINALLY there is an advantage to being FAT.

Typically I am under that calculation ...but for the wrong reason!!!