Information regarding Short-term dialysis from Dr. John Ager's website.

[cdwbrooklyn]

Short daily Haemodialysis – Facility-based or Home-based

Short daily dialysis is not offered by all services though many of us believe it should be. Though I personally do not believe it is the best dialysis available, it is much better than conventional facility-based haemodialysis.

Ideally, you should be able to choose to have short daily dialysis, should you wish it, either in a facility or at home.

As before ... and I freely and openly admit to being one-eyed in this … if you do choose short daily haemodialysis, it will be at its’ best for you at home!

Indeed … I am of the view that all dialysis does best at home if home is at all possible … and I will never be shaken from this conviction!

Make no mistake, facility-based care is good for many. Indeed, it is likely the only possible choice for the elderly, the frail and the alone or for those with multiple other ‘co-morbidities’ (with other major ‘things’ wrong) ...

But ... facility-based care will never quite match the simplicity and effectiveness of home care where home care is feasible.

Short daily dialysis is 5-7 treatments/week – the more, the better.

The treatments are of shorter duration than those of conventional 4 hours per session, 3 times weekly programs.

Short, daily dialysis is typically, 2 or (better) 2.5 hours 6 days/week.

So … how can 6 x 2hr treatments be better than 3 x 4hr treatments?

Doesn’t  2 x 6 = 3 x 4?

Don’t both add up to 12 hours of dialysis a week.

To understand this, look at the following diagram …

 


Spend a little time looking at this graph...

Add together the height of the 3 big ‘peaks’. Compare this with the sum of the height of the 6 little ones.

Though the totals are the same, the big peaks are twice as high and the change from the top to the bottom is twice as great.

Add together the width of the bases of the 3 big ‘peaks’ and the width of the bases of the 6 little ones.

They add up to the same width though the width of each little peak is only ½ the width of each big peak.

Look at the area under each triangle. This represents the amount of waste – or the amount of fluid – that needs to be removed during the treatment. The area under the big triangles is much more … yet the time to remove it is not hugely different.

Think of the upstroke of each peak as the amount of waste and/or the amount of fluid that has built up from the end of one treatment to the beginning of the next (the red dotted lines) and which must then be removed during dialysis … or, if you like, in three 4 hr treatments compared to six 2 hr treatments.

The change representing dialysis waste or fluid removal (the height of the peak height to the valley floor = the green dotted lines) in the less frequent treatment schedule is twice as great as that of the more frequent schedule.

This ‘double-the-amount-of-waste-to-remove’ places twice the stress and strain on the chemistry of the body ... and, there is also twice the amount of fluid to remove as well.

AND…

MOST of the waste is removed early in the treatment … as the blood concentration of waste falls during treatment, the ‘concentration gradient’ falls too … and the rate of removal slows. Looking at the next graph will show you what I mean …


                                   2                                 4                                 6                                  8

% of waste removed
 

Hours of dialysis


You can also think of the area under the curve in this second graph as the amount of waste removed.

These graphs both tell you two things

1.    The longer the dialysis goes on, the more waste is removed.

2.    The more often dialysis is done, the more times the waste removal process is repeated.

Simply put, the more frequent the treatment, the less severe will be the ‘disturbance’ of body chemistry and blood volume as a result of that treatment.

Short, frequent treatment is, simply, gentler.

It is also more efficient – the explanation for this ‘greater efficiency’ is given in the section ‘How dialysis works’.

[cdwbrooklyn]

He is not against short-term dialysis but he mentioned if you choose to do short-term dialysis, it's best if you do it at home instead of in-center. 

It best to read things for yourself. Should you get a chance, please view his website.  It is very interesting.

[noahvale]

*

[Bill Peckham]

Cdw is exactly right on Agar's views ... Strange to say otherwise given the initial post accurately quoted him. Agar thinks home is better in and of itself independent of dose, which he clearly states at any opportunity.

[noahvale]

^

[Bill Peckham]

Cdw is exactly right on Agar's views ... Strange to say otherwise given op accurately quoted him. Agar thinks home is better in and of itself independent of dose, which he clearly states at any opportunity.

As I stated, theortically, there should be no difference.  Hopefully, with incenter NxStage clinics opening up in the U.S. we'll see if Dr. Agar's view holds true.  My greatest problem with incenter care is infection rates.  So, if selfcare is also encouraged in these clincis, then that should not be as much of a concern.

In fact there is a difference in Agar's view infection being an important one far more vectors once you leave the house but Agar also belives that the psychological benifit of doing it yourself has clinical benefits.

[obsidianom]

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  !!

[noahvale]

*

[cdwbrooklyn]

He is not against short-term dialysis but he mentioned if you choose to do short-term dialysis, it's best if you do it at home instead of in-center. 

It best to read things for yourself. Should you get a chance, please view his website.  It is very interesting.

CDWBrooklyn - YOUR conclusion is absolutely incorrect!  Dr. Agar's definition of SHORT-TIME INCENTER DIALYSIS is the traditional 3 treatments a week for 3-4 hours each with the long weekend break.  He would be all for SHORT-TIME DAILY INCENTER DIALYSIS if patients received 2.5-3.5 hour treatment 6 days a week.   In theory, the place of treatment really shouldn't make a difference.   IHD member Chiromac started a topic about how he was starting to go INCENTER for DAILY Nxstage dialysis instead of CONVENTIONAL 3 times weekly dialysis.  Read here...

http://ihatedialysis.com/forum/index.php?topic=29524.msg465259#msg465259

PLEASE, PLEASE, PLEASE understand the difference in the terms of conventional  x3 weekly short-time dialysis of 4 hours or less in duration and short-time DAILY (or at least 6 days a week) dialysis.

Noahvale, bring it down a 1000 - I'm not talking about in-center short term dialysis.  I do understand he is basically talking about short term in center but I was trying to show that he is not aganist short term home NxStage dialysis.  He actually said he more for long term but in-centers should increase their hours or days.   

Sorry if you missed understood my post. 

[cdwbrooklyn]

Cdw is exactly right on Agar's views ... Strange to say otherwise given the initial post accurately quoted him. Agar thinks home is better in and of itself independent of dose, which he clearly states at any opportunity.

Thanks Bill!

[Hemodoc]

Cdw is exactly right on Agar's views ... Strange to say otherwise given op accurately quoted him. Agar thinks home is better in and of itself independent of dose, which he clearly states at any opportunity.

As I stated, theortically, there should be no difference.  Hopefully, with incenter NxStage clinics opening up in the U.S. we'll see if Dr. Agar's view holds true.  My greatest problem with incenter care is infection rates.  So, if selfcare is also encouraged in these clincis, then that should not be as much of a concern.

However the data shows home is better as far as outcomes even with the same TIME on dialysis between the two.

[noahvale]

*

[noahvale]

^

[Hemodoc]

However the data shows home is better as far as outcomes even with the same TIME on dialysis between the two.

Considering how few centers offer the daily (or even x5 weekly) Nxstage or conventional dialysis machine treatment option, please show the data you are speaking.  Thanks.

Dear Noahvale, yes, America has slim offerings, but that is not what I am talking about. More dialysis and more frequent dialysis improves outcomes. I am sure you are quite familiar with the literature. If not a simple Google search will bring up much including Dr. Agar's site, Bill's site, HDC, and many others.

[cassandra]

Just asking: I do mostly 2 shorts(2.30) on 30 ltrs with 1 day off either side, and 2 sessions of 5 hours EOD. Which suites my lifestyle brilliantly. Blood results are even better than on merely SHD. I (maybe naively) believe it gives me the best of both worlds.
Is there a reason why that kind of schedule doesn't get suggested more by 'professionals'?

Love, Cas

[obsidianom]

Just asking: I do mostly 2 shorts(2.30) on 30 ltrs with 1 day off either side, and 2 sessions of 5 hours EOD. Which suites my lifestyle brilliantly. Blood results are even better than on merely SHD. I (maybe naively) believe it gives me the best of both worlds.
Is there a reason why that kind of schedule doesn't get suggested more by 'professionals'?

Love, Cas

Nothing wrong with what you are doing. You are getting 15 hours total dialysis which isnt bad . Another 1 to 2 hours total would be better but you are doing ok so thats good. The only issue with 4 days like you are doing would be in patients who need a lot of UF. Going with Dr. Agars formulas for fluid removal , you need TIME to remove fluid. For patients with a lot of fluid to take off and are small it can require a lot of time on the machine. I assume you are not taking off huge amounts of fluid,  are you?   The other issue with 4 days rather than 5 is more fluid has to be taken off per session with 4 than 5 days. So again it all comes down to each persons fluid removal needs . 4 days is the bare minumum I would want to be on dialysis as the 2 days off on a 3 day schedule is very hard on the body.
Your 5 hour sessions are almost like nocturnal so they are quite helpful. I think the 2.5 hours may be a little short and 3 hours would give you another hour weekly. That would give you 16 hours which is almost the magic 10% of total time that Dr. Agar looks for and seems to work best.
Either way you are doing well so good for you.

[obsidianom]

Noahvale, bring it down a 1000 - I'm not talking about in-center short term dialysis.  I do understand he is basically talking about short term in center but I was trying to show that he is not aganist short term home NxStage dialysis.  He actually said he more for long term but in-centers should increase their hours or days.   

Sorry if you missed understood my post.

CDWBrooklyn - I sincerely apologize to you for responding without first reading your post with Dr. Agar's thoughts.  I'm also glad you see what the difference is between traditional incenter 3-4 hour "short-time" treatment x3 weekly and "short-time" daily (or at least x5 weekly) treatment.

However, I disagree with Dr. Agar's opinion that home short-time is better than comparable in center short time.  This assertion is based on anecdotal observation from his own patient population rather than empirical evidence.  In other words, there aren't enough (or any to my knowledge in the U.S.) patient controlled studies comparing the two modalities to make this statement a fact, or at the least a best practice procedure.

In an earlier post of yours, you stated wanting to hear about "real life" experiences.  Well, here's one of mine.  When I went into kidney failure in 1978, I had basically two choices - either go on hemodialysis at home or incenter or get a transplant.  Peritoneal dialysis was still in its infancy and wasn't a true option, especially in the South, even in "cosmopolitan" Atlanta!  I chose incenter hemo because I didn't have a reliable partner - a nonnegotiable requirement at that time.

There were only 13 dialysis centers in the 10 county metropolitan Atlanta region at that time and only ONE offerred an evening shift that started after 5 pm.  That was my center.  Yet, to get on that shift, patients had to jump through a few hoops.  First, and most importantly, you had to be medically stable because it was a selfcare shift - not just doing your own needling, but set up and tear down, and monitoring your own vitals.  Staffing was 1 tech and 1 nurse for up to 8 patients, and an additional tech if the shift reached a 12 patient limit (that's all the chairs the clinic had at the time).  You also had to be either working or in school.  Next, patients had to have a good understanding of dialysis and fairly good adherence to the renal diet.  Lastly, a willingness to do self care.  It was a big deal to be selected and I can speak for all of us who "graduated" to the self care shift - it was a proud accomplishment and a psychologically satisfying experience.   

Now, for Dr. Agar to say in center patients can't get the same psychological benefit by doing short daily dialysis, doesn't hold well with me - especially without true (and in research terms) replicable evidence.  In a way, he's discounting the diversity and needs of the individual.  What motivates one person might not for another.  It's in this sense, I think you were trying to say all patients (people) are not the same? 

Again my apologies.  In no way was I trying to discount what you have to say.

Best wishes ~ Noahvale

You are doing basically "home dialysis " with your self care. I dont beleive the studies on the differances between home and in center take your type dialysis into account. You control your own treatment and can modulate it the same as any home patient so in effect you get thye same benefits as you dont have rushed techs doing it for you. If more patients did this we would see the morbidity and mortality numbers improve in the US.
Dr. Agar has great insight but like you wrote he is a different world. He has so much going for him in Australia that we dont in the US.  Medicare is the big issue to me as patient and doctor. It only allows 3 days per week paid treatment to the providers. This pushes everyone in center to just 3 days per week which is not enough dialyisis unless it is long nocturnal . As long as medicare only pays for "just enough" dialysis to barely keep patients alive we will continue to see the horrible numbers we see in the US.   I can tell you all kinds of horror stories about medicare that I see as a doctor. Yes it works up to a point but it has HUGE gaps in care.  I am in the middle of an audit on a patient I treated 3 years ago that they are trying to claim the care i gave wasnt "medically necessary".
They never have met the patient and are using strict federal beurocratic guidelines to try to claim the care he required wasnt "necessary".  This despite the fact when he came to see me he was in a power chair form being unable to walk without falling which can lead to traumatic death . When I finished with him he was walking without needing the power chair. To him it was life altering , but to medicare it was "not medically necessary" and basically a waste of taxpayer money. I am in my second appeal of this now and it is taking a lot of my time.
Something else people dont realize is that medicare isnt consistant across the country. Each region has different contractors that administer medicare for that region. Each has different guidelines. In effect where you live can effect your coverage. It is a MESS !!

[cdwbrooklyn]

Noahvale, bring it down a 1000 - I'm not talking about in-center short term dialysis.  I do understand he is basically talking about short term in center but I was trying to show that he is not aganist short term home NxStage dialysis.  He actually said he more for long term but in-centers should increase their hours or days.   

Sorry if you missed understood my post.

CDWBrooklyn - I sincerely apologize to you for responding without first reading your post with Dr. Agar's thoughts.  I'm also glad you see what the difference is between traditional incenter 3-4 hour "short-time" treatment x3 weekly and "short-time" daily (or at least x5 weekly) treatment.

However, I disagree with Dr. Agar's opinion that home short-time is better than comparable in center short time.  This assertion is based on anecdotal observation from his own patient population rather than empirical evidence.  In other words, there aren't enough (or any to my knowledge in the U.S.) patient controlled studies comparing the two modalities to make this statement a fact, or at the least a best practice procedure.

In an earlier post of yours, you stated wanting to hear about "real life" experiences.  Well, here's one of mine.  When I went into kidney failure in 1978, I had basically two choices - either go on hemodialysis at home or incenter or get a transplant.  Peritoneal dialysis was still in its infancy and wasn't a true option, especially in the South, even in "cosmopolitan" Atlanta!  I chose incenter hemo because I didn't have a reliable partner - a nonnegotiable requirement at that time.

There were only 13 dialysis centers in the 10 county metropolitan Atlanta region at that time and only ONE offerred an evening shift that started after 5 pm.  That was my center.  Yet, to get on that shift, patients had to jump through a few hoops.  First, and most importantly, you had to be medically stable because it was a selfcare shift - not just doing your own needling, but set up and tear down, and monitoring your own vitals.  Staffing was 1 tech and 1 nurse for up to 8 patients, and an additional tech if the shift reached a 12 patient limit (that's all the chairs the clinic had at the time).  You also had to be either working or in school.  Next, patients had to have a good understanding of dialysis and fairly good adherence to the renal diet.  Lastly, a willingness to do self care.  It was a big deal to be selected and I can speak for all of us who "graduated" to the self care shift - it was a proud accomplishment and a psychologically satisfying experience.   

Now, for Dr. Agar to say in center patients can't get the same psychological benefit by doing short daily dialysis, doesn't hold well with me - especially without true (and in research terms) replicable evidence.  In a way, he's discounting the diversity and needs of the individual.  What motivates one person might not for another.  It's in this sense, I think you were trying to say all patients (people) are not the same? 

Again my apologies.  In no way was I trying to discount what you have to say.

Best wishes ~ Noahvale

No problem Noahvale, I certainly respect your views as well.  I lasted in-center for 11 years before coming across NxStage.  I don’t knock anyone for wanting to stay in-center.  I really admirer Zack as he is my hero for staying in-center for 32 years, which tells me that people in-center can do well. 
Let me apologize if I came across as knocking people in-center, which was not my intention.   I was a little bothered about this back and forward regarding short-term and long-term dialysis and wanted to know more about this Dr. Agers.   However, when I read his website to my surprised it was not what was bothering me.  I just wanted to share with IHD.   

Nevetheless, you are entitled to your views and I wish my in-center did what you experienced.  I think that was awesome to allow patients to take care of their own treatments.  It means a lot and you learn so much more about your body.  I did not learn about my treatments the way I know it now until I joined IHD and started doing NxStage.   

By the way, I’m hoping that in the near further, the artificial kidneys will work well so dialysis can be a thing in the past.  Wishful thinking….I know dialysis will always exist but hoping it get a lot better in time.

Have a wonderful day!!!!   

[cdwbrooklyn]

Noahvale, bring it down a 1000 - I'm not talking about in-center short term dialysis.  I do understand he is basically talking about short term in center but I was trying to show that he is not aganist short term home NxStage dialysis.  He actually said he more for long term but in-centers should increase their hours or days.   

Sorry if you missed understood my post.

CDWBrooklyn - I sincerely apologize to you for responding without first reading your post with Dr. Agar's thoughts.  I'm also glad you see what the difference is between traditional incenter 3-4 hour "short-time" treatment x3 weekly and "short-time" daily (or at least x5 weekly) treatment.

However, I disagree with Dr. Agar's opinion that home short-time is better than comparable in center short time.  This assertion is based on anecdotal observation from his own patient population rather than empirical evidence.  In other words, there aren't enough (or any to my knowledge in the U.S.) patient controlled studies comparing the two modalities to make this statement a fact, or at the least a best practice procedure.

In an earlier post of yours, you stated wanting to hear about "real life" experiences.  Well, here's one of mine.  When I went into kidney failure in 1978, I had basically two choices - either go on hemodialysis at home or incenter or get a transplant.  Peritoneal dialysis was still in its infancy and wasn't a true option, especially in the South, even in "cosmopolitan" Atlanta!  I chose incenter hemo because I didn't have a reliable partner - a nonnegotiable requirement at that time.

There were only 13 dialysis centers in the 10 county metropolitan Atlanta region at that time and only ONE offerred an evening shift that started after 5 pm.  That was my center.  Yet, to get on that shift, patients had to jump through a few hoops.  First, and most importantly, you had to be medically stable because it was a selfcare shift - not just doing your own needling, but set up and tear down, and monitoring your own vitals.  Staffing was 1 tech and 1 nurse for up to 8 patients, and an additional tech if the shift reached a 12 patient limit (that's all the chairs the clinic had at the time).  You also had to be either working or in school.  Next, patients had to have a good understanding of dialysis and fairly good adherence to the renal diet.  Lastly, a willingness to do self care.  It was a big deal to be selected and I can speak for all of us who "graduated" to the self care shift - it was a proud accomplishment and a psychologically satisfying experience.   

Now, for Dr. Agar to say in center patients can't get the same psychological benefit by doing short daily dialysis, doesn't hold well with me - especially without true (and in research terms) replicable evidence.  In a way, he's discounting the diversity and needs of the individual.  What motivates one person might not for another.  It's in this sense, I think you were trying to say all patients (people) are not the same? 

Again my apologies.  In no way was I trying to discount what you have to say.

Best wishes ~ Noahvale

You are doing basically "home dialysis " with your self care. I dont beleive the studies on the differances between home and in center take your type dialysis into account. You control your own treatment and can modulate it the same as any home patient so in effect you get thye same benefits as you dont have rushed techs doing it for you. If more patients did this we would see the morbidity and mortality numbers improve in the US.
Dr. Agar has great insight but like you wrote he is a different world. He has so much going for him in Australia that we dont in the US.  Medicare is the big issue to me as patient and doctor. It only allows 3 days per week paid treatment to the providers. This pushes everyone in center to just 3 days per week which is not enough dialyisis unless it is long nocturnal . As long as medicare only pays for "just enough" dialysis to barely keep patients alive we will continue to see the horrible numbers we see in the US.   I can tell you all kinds of horror stories about medicare that I see as a doctor. Yes it works up to a point but it has HUGE gaps in care.  I am in the middle of an audit on a patient I treated 3 years ago that they are trying to claim the care i gave wasnt "medically necessary".
They never have met the patient and are using strict federal beurocratic guidelines to try to claim the care he required wasnt "necessary".  This despite the fact when he came to see me he was in a power chair form being unable to walk without falling which can lead to traumatic death . When I finished with him he was walking without needing the power chair. To him it was life altering , but to medicare it was "not medically necessary" and basically a waste of taxpayer money. I am in my second appeal of this now and it is taking a lot of my time.
Something else people dont realize is that medicare isnt consistant across the country. Each region has different contractors that administer medicare for that region. Each has different guidelines. In effect where you live can effect your coverage. It is a MESS !!

Wow, I kind of new that about medicare.  They would not cover my antibiotics treatments for home care.  They wanted me to stay in the hospital in order for it to be covered.  Luckily, I have private insurance as well.   

[obsidianom]

For anybodys info, Dr. John Agar is head of nephrology in Geelong Province ,Australia.  That is like being head of all nephrology in a big state in the US like N.Y.
He is internationally know and respected. He travels and speaks all over the world and writes a monthly blog.
In effect I consider him a "GURU" on dialysis and nephrology. He knows his stuff.
I have had the privalage to communicate with him multiple times and he always takes time to write back and answer my questions . He helped me quite a bit with my wife. He has a GREAT Australian sense of humor. Example -----"Furphys".  He always makes me laugh with his ascerbic wit. 
He does think we in the US are in the dark ages with our manner of dialysis. In general I agree. He doesnt like Nxstage much , and on that I disagree. Of course he has a better system to work with in Australia and 20% of his patients do home hemo.
If you contact him I beleive he will take the time to write back and answer your questions. He seems to like doing that.
Basically he is a great doctor  , teacher , and person.  We are lucky to have him. 

[cassandra]

Thanx for your answer Obsi, but you are right, I hardly need to take fluids off. After nearly 20 yrs restriction, I find it hard to drink, so I keep it as is, and will increase the EOD sessions with one extra session when needed.

Love, Cas