Despite Recent Aluminum Issue Nxstage Still Is Special

[obsidianom]

I was at our monthly clinic today with my wife and also saw our regular nephrologist. It was enlightening. Now I want to first write that this clinic and doctors were against Nxstage way back when we started 2 years ago . We had to push hard to get them to allow us to use Nxstage .
Now at least 8 new patients in our area are using Nxstage .
Today the home nurse told us how much better all the Nxstage patients feel then they did on standard dialysis . In fact 1 patient had to go in center 1 day due to a problem at home and told the nurse how much worse he felt going back to standard dialysis .
Our nephrologist also told us all the Nxstage patients are doing better then in center standard dialysis and feel better. Unlike standard dialysis most Nxstage patients also feel better after dialysis . She is quite impressed.
So we need Nxstage to fix the dialysate problem so we can continue to use this system that is working so well for many patients. I wish more of the people on this board could try Nxstage and see how much better they could feel then standard dialysis .

[Bill Peckham]

I think you're conflating the modality with the device - home more frequent hemodialysis is what leaves people feeling well.

[Speedy1wrc]

I think I may possibly agree with Bill. I for the most part do feel better than in center. I do still have issues although I think at least some are from the aluminum. One significant benefit is lowering my requirement for BP medicine. I am almost off all of it. I likely be lowering it again imminently. All the other advertised benefits are there too. The only glaring difference is the amount of time it takes.

I don't know if it's NxStage or frequent dialysis. If NxStage stumbles and falls I will in all likelyhood switch to a Babyk. I just had another unrelated issue with them today. Even though their computer shows I am short on cartridges for no known reason, they didn't ship me any this month. Doh!

[obsidianom]

I think you're conflating the modality with the device - home more frequent hemodialysis is what leaves people feeling well.

I disagree . WE have now had multiple cases of Nxstage patients here trying the in center standard dialysis for a day or two for various reasons and in each case noticing how much wosrse they felt immedialtly on the in center machine ITSELF .  This has NOTHING to do with the  more frequent dialysis. It is an immediate feeling of fifferance on the 2 machines. Even my originally skeptical nephrologist admitted yesterday that the Nxstage patients all feel better WHILE on the machine and immediatly after unlike the in center patients.
I can go into why at length as I have some well thought out theories involving speed of dialysis and shifts of mollecules from compartment to compartment but in the end all that matters is it appears that Nxstage is more gentle less stressful dialysis . Yes more frequent is important as it allows this but that is the whole concept here. Slow it down and make it gentler.

[Speedy1wrc]

I can't say I felt any different in center to at home in terms of being on one machine or the other. In center I was running at 400ml/min and at home I am 500ml/min so at least from that stand point in center would be gentler. My fistula has definitely grown being at home.

[Simon Dog]

I was on BabyK, switched to Nxstage.  I'm still on the FMC mailing list for the 2008k@home recalls, and just got a letter advising me not to use certain lots of pre-mixed bicard due to bacterial contamination.   A classic "damned if you do and damned if you don't" scenario.

[amanda100wilson]

I have done some in-unit treatments since being on NxStage.  As long as they do what I say, and tell them what to take off, there is no problem, although were I. To go thrice weekly, I know that there would. Be.  I agree with Bill.  Frequency is the key and not taking too much fluid off too quickly is the key, not which machine you are using.

[Speedy1wrc]

I was on BabyK, switched to Nxstage.  I'm still on the FMC mailing list for the 2008k@home recalls, and just got a letter advising me not to use certain lots of pre-mixed bicard due to bacterial contamination.   A classic "damned if you do and damned if you don't" scenario.

That's the scay part. We could all be massively ticked off at NxStage, but is there really a better option?

[Bill Peckham]

I disagree . WE have now had multiple cases of Nxstage patients here trying the in center standard dialysis for a day or two for various reasons and in each case noticing how much wosrse they felt immedialtly on the in center machine ITSELF .  This has NOTHING to do with the  more frequent dialysis. It is an immediate feeling of fifferance on the 2 machines. Even my originally skeptical nephrologist admitted yesterday that the Nxstage patients all feel better WHILE on the machine and immediatly after unlike the in center patients.

I can go into why at length as I have some well thought out theories involving speed of dialysis and shifts of mollecules from compartment to compartment but in the end all that matters is it appears that Nxstage is more gentle less stressful dialysis . Yes more frequent is important as it allows this but that is the whole concept here. Slow it down and make it gentler.

Any standard machine has the ability to run at a slower dialysate flow rate but they don't because that would decrease their effectiveness. The dialysate speed is not what needs to be slowed to provide more gentle dialysis. More gentle dialysis is the ability to remove fluid at a slow rate while using a slower [blood] pump speed.

If you increase the NxStage's dialysate flow rate you will increase the effectiveness of each minute of dialysis at the cost of decreasing the effectiveness of each unit of dialysate. NxStage gets the most dialysis out of each unit of dialysate, standard machines can get the most dialysis out of each unit of time. Solute clearance increases at very nearly a 1:1 rate as dialysate flow increase, ie 2x increase in clearance as dialysate flows go from 100 to 200; 200 to 400. This continues until the dialysate flow rate is greater than the blood flow rate at which point increasing the dialysate flow provides diminishing returns. The fluid dynamic shear is why this is true.

Why would a less effective treatment, minute to minute, feel better?

[obsidianom]

I disagree . WE have now had multiple cases of Nxstage patients here trying the in center standard dialysis for a day or two for various reasons and in each case noticing how much wosrse they felt immedialtly on the in center machine ITSELF .  This has NOTHING to do with the  more frequent dialysis. It is an immediate feeling of fifferance on the 2 machines. Even my originally skeptical nephrologist admitted yesterday that the Nxstage patients all feel better WHILE on the machine and immediatly after unlike the in center patients.

I can go into why at length as I have some well thought out theories involving speed of dialysis and shifts of mollecules from compartment to compartment but in the end all that matters is it appears that Nxstage is more gentle less stressful dialysis . Yes more frequent is important as it allows this but that is the whole concept here. Slow it down and make it gentler.

Any standard machine has the ability to run at a slower dialysate flow rate but they don't because that would decrease their effectiveness. The dialysate speed is not what needs to be slowed to provide more gentle dialysis. More gentle dialysis is the ability to remove fluid at a slow rate while using a slower [blood] pump speed.

If you increase the NxStage's dialysate flow rate you will increase the effectiveness of each minute of dialysis at the cost of decreasing the effectiveness of each unit of dialysate. NxStage gets the most dialysis out of each unit of dialysate, standard machines can get the most dialysis out of each unit of time. Solute clearance increases at very nearly a 1:1 rate as dialysate flow increase, ie 2x increase in clearance as dialysate flows go from 100 to 200; 200 to 400. This continues until the dialysate flow rate is greater than the blood flow rate at which point increasing the dialysate flow provides diminishing returns. The fluid dynamic shear is why this is true.

Why would a less effective treatment, minute to minute, feel better?

I can give you my theory and I base it on physiology . Everyone so far has written about solute clearance from blood to dialysate. That is what the machine does. BUT REMEMBER THERE ARE 3 PHYSIOLOGIC COMPARTMENTS IN THE BODY WITH THE BLOOD BEING THE FINAL ONE BEFORE THE MACHINE. 
What really occurs durng dialysis is the blood is  cleared of various chemicals /toxins and then the same chemicals have to be pulled out of the cells which are one compartment and then travel from the cells to the interstitial areas which are compartment number 2 and then finally to the bllod which is compartment 3.
This is where the speed of the machine comes in to play. The machine can clear faster and faster but the body can only clear from compartment to compartment at certain physiologic speeds which differ for each chemical and person etc.
Bottom line is that based on what I have seen and based on my own physiology knowledge , I have seen that when you speed up the machine pulling from the blood it puts a stress on the body to try and move solutes from the inner compartments back to the blood to equalize the osmolarity through osmosis. Now remember, the normal body does this 24 hours per day if the kidneys work. With dialysis you are speeding this up drastically to under 4 hours . This pushes the body and creates osmotic stresses. The solutes only move so fast from cells to interstitial to blood . Trying to speed it up creates cramping and muscle spasms and makes patients feel crappy.
So bottom line is slowing down the actual dialysis is less stressful on the body physiology. It doesnt force the solutes out of the cells or interstitial compartments as fast and stressfully. Standard dialysis does do that. It has to as it must clear in 12 hours of weekly dialysis what the body does in 168 hours.
Nxstage works slower with a more gentle pull from the blood and thus less pull from the inner compartments. It doesnt jar the body . That is why we also do more time and days on Nxstage . It allows a slower more gentle pull of all molocules , not just water.

[obsidianom]

I was on BabyK, switched to Nxstage.  I'm still on the FMC mailing list for the 2008k@home recalls, and just got a letter advising me not to use certain lots of pre-mixed bicard due to bacterial contamination.   A classic "damned if you do and damned if you don't" scenario.

I wonder if this is also from the same manufacturer as Nxstage uses.? Wouldnt that be interesting. See some of my older posts on all this. I beleive we have an issue with a lot of dialysate made for all types machines.

[Bill Peckham]

Again a standard machine can run at a 100 ml/min dialysate flow rate - it is a simple matter to change the dialysate flow and it can be done before the treatment or while the treatment is in process. You could also choose to use a smaller kidney. Theses options are available to every incenter dialyzor and they save the provider money - cheaper kidneys/less water - but the approach isn't used because low clearance dialysis leaves people feeling unwell unless it is done for a long period of time each treatment or is done more frequently. PD is basically low clearance dialysis that is preformed continuously. Over time just about every combination of time and pump speeds has been tried and evaluated. Kolff's first machine rotated tubing containing blood through a bath of dialysate that did not move at all.


The most novel approach was taken by the Aksys PHD - it reused 50L of dialysate, multipassng it throughout the treatment, this slowed diffusion of small molecules as the treatment went on because as solutes were removed they'd be in the dialysate for the next pass thus the gradient was narrowed over time causing less small solute removal at  the end of the treatment than at the beginning. But throughout the whole treatment the Aksys did a better job removing middle molecules such as protein bound amyloids due to convective clearance - because UFR was greater than 1 l/h - and the large high efficiency F80 kidney it used. For this and other reasons minute for minute the Aksys provided far superior dialysis.

[obsidianom]

The other advantage Nxstage has is Ultra Pure dialysate. I realize this is not the time to bring it up with the aluminum issue, but in reality they generally are ultrapure with no endotoxins or bacteria. There is no question that medically this has proven better for patients. Any contaminants cause inflammation and reactions that damage the vasculature and heart.
In the end the whole concept of longer slower dialysis is the key. I am a firm beleiver in Dr. Agars 10% of time on machine as one key to quality dialysis. That means at least 17 hours per week. (my wife gets 17.5) . Obviously any machine can do this but Nxstage is designed for more frequent slower dialysis and it is far easier to get there with Nxstage as the whole system is easier to set up , run , and break down and clean. It is virtually maintenance free.
Nxstage is not perfect but when it runs as it is supposed to it is easy to run, gentle , and safe .
Our nephrologist asked if we wanted to switch aftyer the aluminum issue and I simply said NO. WE assume nxstage will fix the problem and we will continue to do well with it.
AS a final question I ask this---How many of you out there can go on a dialysis machine for 3.5 hours and then IMMEDIATLY (within 10 minutes) jump on the treadmill for exercise for 30 minutes? My wife does this virtually every day. Even when she feels poorly after a day off dialysis , she perks up on the Nxstage machine and by the end of dialysis is ready to take off on the treadmill. I dont hear of many Fresenius machine patients doing this or feeling better after dialysis. My nurse told us her othe rpatients on nxstage also feel better after dialysis in a similar manner to my wife. This is common and even our skeptical nephrologist admitted she is seeing this also.

[Speedy1wrc]

Actually immediately after treatment I don't feel great. At times I do, but it depends on how much UF I'm trying to do. I will say after treatment I probably do feel better on the NxStage than in center because more likely than not I am removing less fluid due to the frequency of treatment. I gain on average 1.3-1.4L per day and going the extra day without treatment in center was difficult. Trying to pull 2.6-2.8L wasn't working very well. Then over the weekend the additional day meant I was up close to 4L and trying to catch up every week.

[Simon Dog]

I love the fact that pulling 2L is considered a "long gap" (after my day off), and it's often less than 1L on sequential day treatments.   Way better than the in-center 2 or 3 day gap and huge fluid pulls.

[Speedy1wrc]

I love the fact that pulling 2L is considered a "long gap" (after my day off), and it's often less than 1L on sequential day treatments.   Way better than the in-center 2 or 3 day gap and huge fluid pulls.

Indeed!

[Zach]

AS a final question I ask this---How many of you out there can go on a dialysis machine for 3.5 hours and then IMMEDIATLY (within 10 minutes) jump on the treadmill for exercise for 30 minutes? My wife does this virtually every day. Even when she feels poorly after a day off dialysis , she perks up on the Nxstage machine and by the end of dialysis is ready to take off on the treadmill. I dont hear of many Fresenius machine patients doing this or feeling better after dialysis. My nurse told us her othe rpatients on nxstage also feel better after dialysis in a similar manner to my wife. This is common and even our skeptical nephrologist admitted she is seeing this also.

Hi Dr. O,

I think it's great that your wife exercises on the treadmill right after hemodialysis.
Exercise is so important for the health of those of us with ESRD.

Just out of curiosity, how much fluid does your wife remove during treatment?

Thanks,
--Zach

[Maggie and Jeff]

Maggie feels best when we pull 1L or less at .5 per/H

[obsidianom]

AS a final question I ask this---How many of you out there can go on a dialysis machine for 3.5 hours and then IMMEDIATLY (within 10 minutes) jump on the treadmill for exercise for 30 minutes? My wife does this virtually every day. Even when she feels poorly after a day off dialysis , she perks up on the Nxstage machine and by the end of dialysis is ready to take off on the treadmill. I dont hear of many Fresenius machine patients doing this or feeling better after dialysis. My nurse told us her othe rpatients on nxstage also feel better after dialysis in a similar manner to my wife. This is common and even our skeptical nephrologist admitted she is seeing this also.

Hi Dr. O,

I think it's great that your wife exercises on the treadmill right after hemodialysis.
Exercise is so important for the health of those of us with ESRD.

Just out of curiosity, how much fluid does your wife remove during treatment?

Thanks,
--Zach

My wife still urinates so we only pull about .3 liters max.    Also we do it at the speeds DR. Agar writes about which is 5ml/kg/hr as ideal and no faster then 10ml/kg /hr.  In her case she weighs 53 kg so I run at .3 liters/hour speed. This reduces stress on the body as the fluid goes from compartmentto compartment generally   at about 5ml/kg/hour.
I do think speed of fluid removal along with amount is key as is time on machine.

[obsidianom]

ANOTHER BOOST FOR SHORT DAILY DIALYSIS ----FEWER BP MEDS


Short Daily versus Conventional Hemodialysis for Hypertensive Patients: A Randomized Cross-Over Study.

Zimmerman DL1, Ruzicka M1, Hebert P2, Fergusson D3, Touyz RM4, Burns KD5.

BACKGROUND:

Treatment of end stage renal disease patients with short daily hemodialysis has been associated with an improvement in blood pressure. It is unclear from these studies if anti-hypertensive management had been optimized prior to starting short daily hemodialysis. Also, the potential mechanism(s) of blood pressure improvement remain to be fully elucidated.

STUDY DESIGN, SETTING AND PARTICIPANTS:

We undertook a randomized cross-over trial in adult hypertensive patients with ESRD treated with conventional hemodialysis to determine: 1) if short-daily hemodialysis is associated with a reduction in systolic blood pressure after a 3-month blood pressure optimization period and; 2) the potential mechanism(s) of blood pressure reduction. Blood pressure was measured using Canadian Hypertension Education Program guidelines. Extracellular fluid volume (ECFV) was assessed with bioimpedance. Serum catecholamines were used to assess the sympathetic nervous system. Interleukin-6 (IL-6) and thiobarbituric acid reactive substances (T-BARS) were used as markers of inflammation and oxidative stress respectively.

RESULTS:

After a 3-month run-in phase in which systolic blood pressure improved, there was no significant difference in pre-dialysis systolic pressure between short-daily and conventional hemodialysis (p = 0.39). However, similar blood pressures were achieved on fewer anti-hypertensive medications with short daily hemodialysis compared to conventional hemodialysis (p = 0.01). Short daily hemodialysis, compared to conventional hemodialysis, was not associated with a difference in dry weight or ECFV (p = 0.77). Sympathetic nervous system activity as assessed by plasma epinephrine (p = 1.0) and norepinephrine (p = 0.52) was also not different. Markers of inflammation (p = 0.42) and oxidative stress (p = 0.83) were also similar between the two treatment arms.

CONCLUSIONS:

Patients treated with short daily, compared to conventional hemodialysis, have similar blood pressure control on fewer anti-hypertensive medications. The mechanism(s) by which short daily hemodialysis allows for decreased anti-hypertensive medication use remains unclear but effects on sodium balance and changes in peripheral vascular resistance require further study.

[Speedy1wrc]

Fact

[caregivertech1]

As I've indicated here before my wife went back in center twice this year to remove aluminum at dialysate flow of 700 vs 175 on NxStage. I gotta tell you the center treatment hammered her each treatment. Typically I would walk her to the car then home for a 2 hour nap. She normally feels great after Nxstage and does all kind of stuff.

[Hemodoc]

I think you're conflating the modality with the device - home more frequent hemodialysis is what leaves people feeling well.

So true Bill. That is the message DSEN has had for several years.