My clearence isn't as good as it should be

[Adam_W]

I saw my doctor today, and we reviewed my monthly labs. Most of the numbers looked fairly well, but my kt/v has dropped to 1.9. That's lower than it was even when I was in-centre. My doctor had me increase my dialysate volume from 15 L to 20 L, and we will probably end up tweaking around my filtration fraction (it is 30 now). I was on the machine a little bit longer today, 2:45 min. taking off .8 kilos of fluid (before my tx was usually around 2:00 when taking off that amount). I'm actually not too surprised because 1, I've gained about 40 pounds since I first started dialysis (90 lbs up to 130 lbs), and 2, my residual kidney function is continuing to decrease (it's practically nothing now). Now I'm definitely looking forward to starting nocturnal, which shouldn't be to long from now, since NxStage should be FDA certified for nocturnal by the end of this month or the beginning of next (at least according to what my nurse has heard). Short-daily still beats the HELL out of in-centre.

Adam

[Black]

Mike had a similar discussion about his KT/V today.  His has been between 1.8 and 1.9 and they would prefer it be around 2.2.  They have already upped his dialysate to 25 L and time to around 2:58, FF is 30, blood speed 500, usually takes off .6 or .7 and processes 88 or 89 liters of blood .  He took blood to them today so we'll know more when we get the results.

The only thing they mentioned as to a cause for the low KT/V was that there may be something going on with his fistula and he may need to get some pics to see what it looks like on the inside.  I think that is ridiculous as he gets no pressure alarms at 500 blood speed and his pressures are fine.  I suspect it is due to his size - 124 kg at 6 feet tall and his residual kidney function is continuing to decline

It doesn't help that 5 to 10% of the blood tubes in many of the filters are clogged with glue and stay white for the entire treatment.  I assume NxStage is still working on that.  (NOTE: The newer cartridges are much better.)

As you said, it still beats the hell out of in-center.

[Bill Peckham]

I just got a call today that when I get back from vacation I  am cleared to try nocturnal. My plan is to try a mixed schedule. I hope to do two or three nocturnal 30L runs on the weekend and then do 3 or 4 20L short runs during the week. Adam would you use 30L if you did nocturnal? The amount of dialysate has a lot of impact in my experience. Seems to me that in general dialyzors should be encouraged to try a couple 30L runs just for comparison sake. What would be the downside of trying various combinations of FF and dialysate quantity?

[KR Cincy]

We got the ok to try adjusting our schedule a little to get an additional day off now and again. I do appreciate the flexibility the NxStage offers for things like this.

[Black]

I just got a call today that when I get back from vacation I  am cleared to try nocturnal. My plan is to try a mixed schedule. I hope to do two or three nocturnal 30L runs on the weekend and then do 3 or 4 20L short runs during the week. ... The amount of dialysate has a lot of impact in my experience. Seems to me that in general dialyzors should be encouraged to try a couple 30L runs just for comparison sake. What would be the downside of trying various combinations of FF and dialysate quantity?

    Two or three nocturnal runs will certainly give you more free hours during the day.    

Maybe that's what we need to try with Mike - more dialysate.  He's currently using 25L.  Using the PureFlow he could use up to 30L and still get two sessions out of a batch.  I think I'm going to suggest that.

[jbeany]

Adam - 2 hours and 45 minutes for 20 L?  What speed are you running?  I've been doing 20 L since I started, and I usually average about 2 hours and 15 minutes, regardless of how much fluid I have on. ( I set my UF rate according to how much fluid I have on - divide my goal in two and set the rate to take it off so I'm always done with UF at the end of the first two hours. If I have .8 on, my UF rate is .4; If I have 1.8, my UF rate is .9.)  Depending on my access and how good my needle placement was for the day, I can usually run between 450 and 470.  Can you get them to bump up the fluid fraction?  I'm at 35%.  The notes I have say the NxStage reccomendations are a number between 33 and 35, with lower numbers only for excessively large patients, which you certainly don't qualify for!

Don't forget to up your heparin if you have to run longer!

[skyedogrocks]

Rob's clearances haven't been that good either, the Neph thinks that the dirty blood is being recirculated.  So, they have him doing 1 day in center and he had a fistula gram on his 2 fistulas.  Rob isn't happy with the  in center, this is why he went on NxStage, to stop it!

The surgeon was actually able to balloon his lower fistula, big news for Rob since he was told it could never be done.  His upper arm fistula looks a bit too deep, so they are wondering if they have to raise it up.  It's been over 6 months and should be working fine now.  On Saturday a nurse was actually able to use his upper arm for venous and lower arm for arterial. 

He did his pre/post last night.  I'm curious to see his output.  Rob didn't go in-center twice this month, but did it regularly at home.

[JerseyGirl]

Nocturnal is the way to go.  I have minimal faith in NxStage's ability to provide consistently above average clearance.  I know you all love it but the more I read about it I am convinced NxStage is not delivering what it is supposed to - including all the manufacturing problems they've been having and no good data to support long term therapy.  #1 problem is the lack of adequate dialysate delivery.  No large or middle molecule clearance also.  Fluid removal appears to be ok but that was what it was designed to do in a critical care environment for patients with low cardiac output.  Fluid removal is secondary to solute removal.  Why go through all the fuss of cannulating 6x/wk, set up, etc for inadequate therapy?  Nocturnal or Fresenius K @ Home or any conventional dialysis machine for home use is far far superior. Can't beat a 600-800cc Qd. Not to mention the water quality issues with the NxStage as well.  Quality will also decrease when NxStage and its carriers find the cost of parts, etc is too much to bear when reimbursement is so low. Think ahead!

[kidney4traci]

My clearance wasn't what it was in center either, and just bumped me from 15 to 17L.  I used to run 2 hours, 5x/wk but now run closer to 2.5 hours, still 5x/wk.  My creatine was high too, 12 still.  ??

[Black]

...Not to mention the water quality issues with the NxStage as well. ...

Water quality problems?

[JerseyGirl]

I just don't have faith in their water purification system.  I guess I am used to the tried but true standards of double carbon tanks, water softener and micron filters that are standard with the other machines.  I know the water is purified via UF lights for bacteria and endotoxins but I don't trust them - I have read here that you have to change those filters quite often to assure that they work correctly, and it sort of bothers me that there was a most recent CMS warning about changing that filter and the fact that there is not even a proper port to sample.  I read on another site about a problem one family was having with high levels of aluminum in the incoming water so much so to the point where the patient's aluminum level was sky high.  There is a great post over on HomeDialysisCentral from an Australian physician about adequate dialysis where there is discussion of nocturnal vs SDD - he discussed middle & large molecule removal on SDD vs nocturnal.  I can't even get info on the dialyzer coefficient for the NxStage cartridge - is it comparable to a Optiflux 160, 180 or 200?  I think that if you are going to spend all the effort on 6x week dialysis for 2.5 - 3.0 tx get more bang for your buck and go the longer treatment route with a good hiflux dialyzer and a higher dialysate flow.  I think there is too much emphasis on daily fluid removal on the NxStage but again dialysis is not about fluid removal it is about solute removal and long term affects of substances building up that are not being dialyzed out because the NxStage cartridge or filter is just not designed to do it. Plus it is a fact that you get better dialysis with higher dialysate rates, and the NxStage can't deliver on this.  Just my opinion, but I've been a dialysis RN since 1986 and have been studying this for many years. I also think the probability of patient burn out is higher with the NxStage form of therapy as well, all the set up, testing, cannulating, etc daily can certainly wear one out.

[Bill Peckham]

FWIW Pat's aluminum issue was with her pots and pans not with the incoming water.

The new CMS conditions of coverage mention the NxStage PureFlow twice which I think is the first time the CoCs have mentioned a specific product. I don't know what to make of that.

With each box of System One cartridges there is an insert that provides additional technical information on the artificial kidney. One chart shows the impact of Qd on clearances- it is a nearly linear relationship i.e. if Qd doubles, clearance (of small easily removed urea) doubles. While changes in the FF have only a small, nearly inconsequential impact. The main impact of changing FF comes from simply dialyzing longer which allows additional time for solute transfer from the intracellular space to the blood compartment.

Dr. Agar's position is more against short daily than the System One per se but the lack of independent data about the System One makes it hard for anyone to say conclusively what clinical impact it provides. My fall back position is to listen to what people report about their personal experience and in general those who have switched from the H or K to the System One like what they experience so I conclude there is something going on that is not explained by conventional wisdom.

I could switch back to the B Braun if I choose but I want to experience nocturnal on the System One first.

[zekewolfy]

Wow!!! 2.5 hour run time om NXStage 5 times a week!! You are a lucky camper! i have to run 6 hours at almost 3:45 mins a shot. Unfortuantely for these jokers(my new nurses) I can only run 5x a week, as six is just too much; they forget some of us work full time.
Also the fact the healthcare team is number "3" on my list..Family, Career come first. I'd rather die a few years earlier and enjoy my life, then dialyze 24/7 and live in misery. It's your life, if you feel good and they are pushing you to do too much just say: TOUGH!!!! GET OVER IT.

[KR Cincy]

I'm running about 3 1/2 hours, 5 days a week, 26L of dialysiate, 450 blood flow, 29% UF and getting good adequaciies. I have zero kidney function, am 6'4" and about 118 kilos. It's a long treatment, but as has been said here before, beats going to the center!

[skyedogrocks]

Rob has a 5 day schedule with 20L of dialysiate running at a speed of 500 for 2 1/2 hours.  This works for him.  He will be starting to use his new graft soon, which means a longer run time on 17 needles for a while.  In the end though, he'll get better clearances with a better access, yeah!

[jbeany]

Something I've learned about the clearances - it depends on what day you take the blood draw.  I do 3 on, 1 off.  If I do a blood draw on day 1, my clearances are 1.9 or 1.8.  On day 2, I get 2.3 or 2.4.  If I'm rearranging my schedule, and end up doing 4 days in a row, blood work from day 4 shows my clearance is over 3.5.  So if you are getting grief about low clearances, make sure you are not doing the lab work after a day off! 

[Roadrunner]

Something I've learned about the clearances - it depends on what day you take the blood draw.  I do 3 on, 1 off. 

That is interesting.  We do the same.  Drew Dick's blood on Monday (day 1), we will get the results tomorrow.  I wonder if that also applies to his potassium and phosphorus levels also.  If that is true then what is the norm?

[jbeany]

The NxStage trainer at my clinic apparently had recommended that all blood work be done on Day 2 or 3.  I didn't realize that until I got such odd results  - the 3.5 one month, after a 1.8 the month before.  I suppose the same would be true for other labs as well as the clearance.  The day off would likely skew those results as well.

[Adam_W]

I always draw my blood on Wednesday, and I'm usually off on Sunday, so I'm pretty sure that round of labs was not drawn right after a day off. After a while on 20L and FF35, my numbers shot up higher than the nurses had ever seen before (or so they told me). I was backed down to 18L, and the numbers stayed really good (kt/v around 2.9). My last round of labs, my numbers were down again (something like 1.8 for kt/v). We think the drop may be caused by my catheter recirculating wastes. I've been using my catheter 99% of the time, even though my graft still works (barely), and it may be time for a new one. Speaking of my psychotic graft, the last couple days I've been using it for the arterial line and using the cath for the venous, and the bloody thing is working perfectly! The best pressures I've seen, and absolutely no excessive bleeding. I'm definitely not complaining, but I wish the stupid thing would make up it's mind. I'm not going to hold my breath for it to continue working good for much longer. Oh well, I'll manage.

Adam

[skyedogrocks]

Rob has his labs drawn on day 3 also.  His labs are much better than if he did it on day 1.

[cherpep]

Great information.  As a new home hemodialysis patient, I have only had to draw labs once so far.  Now, I will be sure to schedule my labs so that they are never on day 1.  Thanks!!