Pearls of Wisdom by Dr. Agar (safe fluid removal)

[obsidianom]

Another GREAT piece of writing by Dr. Agar. Every dialysis patient should read this .

http://homedialysis.org/news-and-research/blog/44-volume-safe-dialysis-duration-kpi

[noahvale]

*

[obsidianom]

From my other post.

Everyone should read my post today with the link to Dr. Agars latest that just came out today. He again discusses the speed of fluid removal and the fastest times it should be done . He gives mathmatical formulas to show the exact amount of time needed to SAFELY remove fluid without stunning or crashing the system.
I have had multiple oportunities to directly discuss this with him and his big focus is slowing down the blood speed to under 350 , time on machine of at least 10% of total time which works out to 17 hours per week, and not going faster with fluid removal than the magic number of 10ml /kg/hour . He actually beleives 5ml/kg /hour is safer and more physiologic but reality is 10 is probably the best we can do and that is the upper limit before stunning occurs.
 (see his article on my other post. )
When you look at the 3 things I listed above it is really quite simple.  --- 1 SLOW DOWN BLOOD -----  2.   17 HOURS WEEKLY OR MORE ON MACHINE----3. SLOW DOWN FLUID REMOVAL TO UNDER 10 ML/KG/HOUR.         
Do all these and you have safe adaquate dialysis.   PERIOD  !!

[kporter85db]

So, if I understand the Volume-safe Dialysis Duration (VsDD) formula:

KPorter
(typical) Weight gain = 2Kg
Volume to remove = 2000 mL
Pre-dialysis Weight = 164 Kg
VsDD = 2000/10 x 164 = 2000/1640 = 1.22 hrs

So, in my example, Kt/V would then take over as the duration-defining KPI (Key Performance Indicator)

Actually, I fall well within the ideal of 5ml/kg/hr as my current treatment time is right at 3 hrs.

Obsidianom, Is my thinking clear on this?

[obsidianom]

So, if I understand the Volume-safe Dialysis Duration (VsDD) formula:

KPorter
(typical) Weight gain = 2Kg
Volume to remove = 2000 mL
Pre-dialysis Weight = 164 Kg
VsDD = 2000/10 x 164 = 2000/1640 = 1.22 hrs

So, in my example, Kt/V would then take over as the duration-defining KPI (Key Performance Indicator)

Actually, I fall well within the ideal of 5ml/kg/hr as my current treatment time is right at 3 hrs.

Obsidianom, Is my thinking clear on this?

You are right on. Good job. The 5ml/kg/hour is the better number and you are easily doing it. That is the speed the body can refill from compartment to compartment and is "physiological". It is better then the 10 ml/kg/hour maximum. So keep up the good work. I assume you feel pretty good on this.
Again the only thing you may want to look at is the total time on dialysis . The magic number is 10% time which is 16.8 hours weekly. If you are doing 5 days at 3 hours you are slightly low.  (I try to get my wife who is only 53 kg 3.25 hours at 5 days to get 16.25 hours.  It is only another 15 miutes over 3 hours but adds an hour and a quarter total and is just about 10% time. )

[talker]

Another GREAT piece of writing by Dr. Agar. Every dialysis patient should read this .

http://homedialysis.org/news-and-research/blog/44-volume-safe-dialysis-duration-kpi

                      
I am not sure of 'what these actually refer too, or mean':
 

        from  Dr. Agar's article
The necessary duration for any particular dialysis treatment can be easily predicted before the start of that treatment. (1) the pre-dialysis weight is known.

(2) the target post dialysis weight is known, noting that this target weight is not necessarily the same as the ideal dry weight     

I have no idea what I actually weighed before the kidney's acted up. 
Do believe it was around 174 lbs / 79.09 kg. 
My dry weight is currently set at 84.5 kg (W/shoes,trousers, shirt) (with occasional low blood pressure warnings)
My at home weigh-in (in PJ's) is a variable between 180 / 181 lbs 
Am I to believe that the 6 lbs / 2.72 kg difference between 174 lbs / 79.09 kg and the 180 / 181 lbs / 81.8 / 82.2 kg is what still needs to be 'removed' !   
Same applies here, what would one use  for the 'target post dialysis weight is known'! 

Sheesh! 
Life used to be so simple.
Don't let Ma/Pa catch you drunk. Bring the car home in the same shape as when you drove off in it.
Don't mistake the 55 gallon tanks of gasoline and kerosine when filling the tractor or lamps.

talker

[obsidianom]

Another GREAT piece of writing by Dr. Agar. Every dialysis patient should read this .

http://homedialysis.org/news-and-research/blog/44-volume-safe-dialysis-duration-kpi

                      
I am not sure of 'what these actually refer too, or mean':
 

        from  Dr. Agar's article
The necessary duration for any particular dialysis treatment can be easily predicted before the start of that treatment. (1) the pre-dialysis weight is known.

(2) the target post dialysis weight is known, noting that this target weight is not necessarily the same as the ideal dry weight     

I have no idea what I actually weighed before the kidney's acted up. 
Do believe it was around 174 lbs / 79.09 kg. 
My dry weight is currently set at 84.5 kg (W/shoes,trousers, shirt) (with occasional low blood pressure warnings)
My at home weigh-in (in PJ's) is a variable between 180 / 181 lbs 
Am I to believe that the 6 lbs / 2.72 kg difference between 174 lbs / 79.09 kg and the 180 / 181 lbs / 81.8 / 82.2 kg is what still needs to be 'removed' !   
Same applies here, what would one use  for the 'target post dialysis weight is known'! 

Sheesh! 
Life used to be so simple.
Don't let Ma/Pa catch you drunk. Bring the car home in the same shape as when you drove off in it.
Don't mistake the 55 gallon tanks of gasoline and kerosine when filling the tractor or lamps.

talker

What you weighed before kidney disease is really not relevant here. What is important is how much you gain between dialysis treatments. that is what needs to be removed. If you weigh aqround 181 pounds or  82.3 kg you would then limit your UF rate to no more than .82 liters per hour . That is maximum. A safer slower removal is even better. Basically you need enough time on machine to go slower than .8 liters per hour.  I am a beleiver in going as slow as possible with UF to reduce the stress on the organs. That is what Dr. Agar is writing about.

[talker]

Another GREAT piece of writing by Dr. Agar. Every dialysis patient should read this .

http://homedialysis.org/news-and-research/blog/44-volume-safe-dialysis-duration-kpi

                      
I am not sure of 'what these actually refer too, or mean':
 

        from  Dr. Agar's article
The necessary duration for any particular dialysis treatment can be easily predicted before the start of that treatment. (1) the pre-dialysis weight is known.

(2) the target post dialysis weight is known, noting that this target weight is not necessarily the same as the ideal dry weight     

I have no idea what I actually weighed before the kidney's acted up. 
Do believe it was around 174 lbs / 79.09 kg. 
My dry weight is currently set at 84.5 kg (W/shoes,trousers, shirt) (with occasional low blood pressure warnings)
My at home weigh-in (in PJ's) is a variable between 180 / 181 lbs 
Am I to believe that the 6 lbs / 2.72 kg difference between 174 lbs / 79.09 kg and the 180 / 181 lbs / 81.8 / 82.2 kg is what still needs to be 'removed' !   
Same applies here, what would one use  for the 'target post dialysis weight is known'! 

Sheesh! 
Life used to be so simple.
Don't let Ma/Pa catch you drunk. Bring the car home in the same shape as when you drove off in it.
Don't mistake the 55 gallon tanks of gasoline and kerosine when filling the tractor or lamps.

talker

What you weighed before kidney disease is really not relevant here. What is important is how much you gain between dialysis treatments. that is what needs to be removed. If you weigh aqround 181 pounds or  82.3 kg you would then limit your UF rate to no more than .82 liters per hour . That is maximum. A safer slower removal is even better. Basically you need enough time on machine to go slower than .8 liters per hour.  I am a beleiver in going as slow as possible with UF to reduce the stress on the organs. That is what Dr. Agar is writing about.

Thank you.

talker

[kporter85db]

So, if I understand the Volume-safe Dialysis Duration (VsDD) formula:

KPorter
(typical) Weight gain = 2Kg
Volume to remove = 2000 mL
Pre-dialysis Weight = 164 Kg
VsDD = 2000/10 x 164 = 2000/1640 = 1.22 hrs

So, in my example, Kt/V would then take over as the duration-defining KPI (Key Performance Indicator)

Actually, I fall well within the ideal of 5ml/kg/hr as my current treatment time is right at 3 hrs.

Obsidianom, Is my thinking clear on this?

You are right on. Good job. The 5ml/kg/hour is the better number and you are easily doing it. That is the speed the body can refill from compartment to compartment and is "physiological". It is better then the 10 ml/kg/hour maximum. So keep up the good work. I assume you feel pretty good on this.
Again the only thing you may want to look at is the total time on dialysis . The magic number is 10% time which is 16.8 hours weekly. If you are doing 5 days at 3 hours you are slightly low.  (I try to get my wife who is only 53 kg 3.25 hours at 5 days to get 16.25 hours.  It is only another 15 miutes over 3 hours but adds an hour and a quarter total and is just about 10% time. )

Actually, I need to work on two things:

~Since I got the new System One S I am only doing 4 treatments a week at three hours each. I was doing 5 x 3.5hrs on the System One. So that was 17.5 hrs vs. 12 hrs now.

~I am currently running a blood pump speed of 450. I need to get that down to below 350.

The thing is: I am unable to set up the machine by myself so I have to be cognizant of my wife's time (she is very busy). But the goal is to be doing nocturnal 4 nights a week or EOD within the next two months. This will fix all the above issues by default. If I go EOD at just 7 hrs/ session that will give me 28 hrs one week and 21 hrs the next for an average of 24.5 hrs per week.

We are going to do a trial run tomorrow at a BPS of 350 and see what time that gives us. I can get to 16 hrs a week just by adding one hr per treatment.

I've been doing this current schedule for two and a half weeks and I still feel great.

[obsidianom]

So, if I understand the Volume-safe Dialysis Duration (VsDD) formula:

KPorter
(typical) Weight gain = 2Kg
Volume to remove = 2000 mL
Pre-dialysis Weight = 164 Kg
VsDD = 2000/10 x 164 = 2000/1640 = 1.22 hrs

So, in my example, Kt/V would then take over as the duration-defining KPI (Key Performance Indicator)

Actually, I fall well within the ideal of 5ml/kg/hr as my current treatment time is right at 3 hrs.

Obsidianom, Is my thinking clear on this?

You are right on. Good job. The 5ml/kg/hour is the better number and you are easily doing it. That is the speed the body can refill from compartment to compartment and is "physiological". It is better then the 10 ml/kg/hour maximum. So keep up the good work. I assume you feel pretty good on this.
Again the only thing you may want to look at is the total time on dialysis . The magic number is 10% time which is 16.8 hours weekly. If you are doing 5 days at 3 hours you are slightly low.  (I try to get my wife who is only 53 kg 3.25 hours at 5 days to get 16.25 hours.  It is only another 15 miutes over 3 hours but adds an hour and a quarter total and is just about 10% time. )

Actually, I need to work on two things:

~Since I got the new System One S I am only doing 4 treatments a week at three hours each. I was doing 5 x 3.5hrs on the System One. So that was 17.5 hrs vs. 12 hrs now.

~I am currently running a blood pump speed of 450. I need to get that down to below 350.

The thing is: I am unable to set up the machine by myself so I have to be cognizant of my wife's time (she is very busy). But the goal is to be doing nocturnal 4 nights a week or EOD within the next two months. This will fix all the above issues by default. If I go EOD at just 7 hrs/ session that will give me 28 hrs one week and 21 hrs the next for an average of 24.5 hrs per week.

We are going to do a trial run tomorrow at a BPS of 350 and see what time that gives us. I can get to 16 hrs a week just by adding one hr per treatment.

I've been doing this current schedule for two and a half weeks and I still feel great.

You can set the flow fraction to over 100% in the back settings so it wont have any effect on what you do. Then you can just decide how long you want to run the machine and set the DIALYSATE SPEED to what ever gives you the time you want. Dont let the flow fraction be the decider, take it out of the equation.
By running longer you will get more blood through the machine and can lower the blood speed to still get a lot of blood filtered. The mistake we make in the Us is running shorter time and having to run faster blood speed to make up for it to get enough blood through the machine. 450 is hard on the fistula and can cause damage and stenosis and anuerism. It is also hard on th heart.
So your idea of night hours makes sense.

[Dman73]

K.I.S.S principal...

Keep your weight gain to a minimal (2kg) between treatments which is easy for the machine and your body to remove in a 4 hr treatment 3X/week @ 350 flow.

This can be achieved by not drinking anything (only to take pills) and when you absolutely need to quench your thirst just rinse your mouth as you would with mouthwash. This satisfies your thirst and refreshes your mouth and you feel like you had a drink without having the weight gain. It can be done in a public place or water fountain surreptitiously with a little skill (draw a mouthful with a straw/swish it around and then return via straw - works well with drink with lots of ice and with a water fountain do the same without straw returning mouthful into water flow).

These methods may not be socially appealing but they are D survival techniques that have worked well for me as I approach 41 yrs D anniversary on May 1st.

                          good luck to you all ...

[ianch]

Oh I so hate Kt/V it really sucks as people think they can decrease time like recharging a battery.

Thats not what Dr A or myself are saying.  Only 10% of toxin resides in the blood so to remove toxin from tissues the body needs time to pull it out.  I do 10hr treatments with a QB of 225 and I have an almost normal very active life very few meds (just blood cell generators).

But thats not all, with our software I have tested the problem of dialysis and brain fog on over 250 sessions by tweaking the program and reporting it.  I've discovered a direct link between brain fog and fluid removal. 

In my 12 hr session tests with a fluid target of 1.7L, I profiled it as 400ml * 2hr, 300ml * 1hr, 200 * 1hr, and the balance over 8 hours was 37ml per hour.  Post this session my mind was clear my physical energy was high and the resulting day was hugely productive.

Fluid profiling is not supported by many home machines and so it should not be done as it can be very dangerous.  I'm using my machine as a research vehicle to assist in understanding how to make treatments better.

   

 

So, if I understand the Volume-safe Dialysis Duration (VsDD) formula:

KPorter
(typical) Weight gain = 2Kg
Volume to remove = 2000 mL
Pre-dialysis Weight = 164 Kg
VsDD = 2000/10 x 164 = 2000/1640 = 1.22 hrs

So, in my example, Kt/V would then take over as the duration-defining KPI (Key Performance Indicator)

Actually, I fall well within the ideal of 5ml/kg/hr as my current treatment time is right at 3 hrs.

Obsidianom, Is my thinking clear on this?

[obsidianom]

Ianch, I moved this from Nxstage for all to see. It tends to sgree with your findings as many toxins cant be removed quickly. Urea is easy to move and non toxic . The others like p-cresol are toxic. Time on machine is critical. We just added 15 minutes daily for my my wife (5 days per week) and she already feels better. Every 15 minutes is life saving.


Another advantage to near daily dialysis such as Nxstage is removal of uremic toxins that are protein boundand and hard to remove.

"Removal of indoxyl sulphate and p-cresyl sulphate(p-cresol) can be improved to some extent by increasing the diffusion of the free forms with super-flux membrane HD, increasing the dialyzer transfer area coefficient and dialysate flow, haemodiafiltration,daily HD,------"

Notice that last 2 words, daily HD.  These toxins are very hard to remove with standard 3 day dialysis unless there is more time .


On the other hand note this :

"p-Cresol is a major component in pig odor.[2]
 
p-Cresol is a component in human sweat. It is a component of human odor attractive to female mosquitoes.[3]
 
Temporal glands secretion examination showed the presence of phenol and p-cresol during musth in male elephants.[4][5]"

So guys and gals, we are full of p-cresol that is hard to dialyze out and its in pig sweat, human odor that attracts FEMALE mosquitoes, and male elaphants in musth. There are a WHOLE lot of wise ass remarks I can make about this. Especially to guys and pigsweat and attraction to females----oops , mosquitoes. and like elephant musths.
So the moral of the story, DAILY DIALYSIS TO REDUCE PROTEIN BOUND P-CRESOL or you smell like pig sweat and attract female mosquitoes while in musth. 

[talker]

 


 


 

 

talker