Cramping on NxStage

[cherpep]

Since starting home hemo, I have had a lot of problems with cramping.  Of course, the standard answer from my nurse administrator is that I'm pulling off too much liquid.  However, it doesn't matter how much I'm pulling off.  I can be 3 kilos over my dry weight, and only pull off 1, and I'll start cramping after about 2 hours on the machine.  It doesn't happen every night, but it does happen a few times a week.   I've been through childbirth without drugs, had a cathetar inserted in my groin without pain medication, and never took pain meds after fistula surgery.  I can tolerate a lot of pain, but these cramps bring me to tears.  I've tried raising my dry weight and not pulling off all the fluid, but the cramps still occur and I can see and feel the extra fluid remaining in my ankles.  The doc gave me some medicine to increase my blood pressure during dialysis, and that seems to be helping a little, but not enough.  I've even tried eating extra potassium before dialysis - a tomato or banana or orange - not really helping.  I've tried getting a little saline when they start, but that doesn't make much of a difference either, and I end up with more fluid.  I hate ending the session early, and try to make it through with my husband or my son massaging my legs.  But sometimes, I cannot take it and we just have to end it.  We have also tried just stopping it from pulling fluid, but that never makes any difference.

I run at at UF rate of 450 max, generally pulling off 1-2 liters per session (5 days/week).  My blood flow rate is 78.  The total Tx time is usually 3 hours.

Does anyone else experience this?  Is there any kind of drug that can help alleviate the pain instantly so that I can finish my session?

[Zach]

Maybe the sodium or conductivity is set too low.
Just a thought, although I am not on NxStage.
 

[flip]

I read somewhere that you can cramp if conductivity drops below 13.7

[Rerun]

They use to perscribe Quinine Sulf Tab 260mg here in the States freely for dialysis patient's cramping.  Now they have stopped.  But, if you can talk your doc into giving you some it really worked for me.  It is usually perscribed for Malaria.

                                      

[cherpep]

How do I know what my conductivity is on NxStage?  Is that one of the monitors?

[jbeany]

As far as I know, there isn't a conductivity setting on the NxStage - at least not one the patient can access.

Have you tried a different Sak?  Something with a different K level?  I had to switch from 002 to 004 because my potassium was too low.  Perhaps that might affect the cramps?

[monrein]

I asked two of the nurses at dialysis about this today and they said that the conductivity (bicarb) and the sodium levels of the machine can cause cramping.  They said that the two levels are usually the same so my bicarb level is set for 14.0 (total bicarb) altho it often runs at 13.9 and the sodium number is similar.  Jbeany's suggestion about the potassium is a good idea to check into as well.  I hope you get an answer and a remedy soon from your technical team.

[skyedogrocks]

Geez, I don't know anything about these levels, but Rob cramps at times.  In fact tonight was his worst cramp ever, we had to end treatment early because if it (about an hour early).  Rob's cramping though is due to too much fluid coming off because his dry weight went up.

[monrein]

Well that will definitely do it.  What happens if you just give some saline if you've taken too much off?

[Bill Peckham]

Have you been trained on doing a dry weight evaluation? It can be surprising how fast weight changes with increased dialysis.

What did you man by a blood flow of 78? Liters processed? UFR rate of .45? Can you run through all your numbers?

Blood Flow Rate (is that 450?)

Fluid removal rate and total fluid removal target

Dialysate rate (liters/per hour) (that could be 7.8)

The NxStage uses a lactate based dialysate there isn't a conductivity measure let alone a setting. A low potassium is dangerous and should be closely monitored.

[cherpep]

Trained on doing a dry weight evaluation?  I never heard of that.  What does that entail?  There are some sessions where I don't pull off any fluid, but I still have cramps.  This is one of the reasons I don't believe it's related to my dry weight. 

My Blood Flow Rate is 450
My Ultrafiltration Volume is usually 1 to 2 liters. 
My Ultrafiltration rate is .78
I usually run about 3 hours.
My blood pressure always drops.  With the medication, I generally end with the top number around 90. 

[Bill Peckham]

Trained on doing a dry weight evaluation?  I never heard of that.  What does that entail?  There are some sessions where I don't pull off any fluid, but I still have cramps.  This is one of the reasons I don't believe it's related to my dry weight. 

My Blood Flow Rate is 450
My Ultrafiltration Volume is usually 1 to 2 liters. 
My Ultrafiltration rate is .78
I usually run about 3 hours.
My blood pressure always drops.  With the medication, I generally end with the top number around 90. 

A dry weight evaluation varies from person to person - after 18 years I think I know my dry weight by feel. However as you say this might not be fluid related since you get symptoms separate from pulling fluid. One last question - do you still have urine output?

The ultrafiltration rate varies treatment to treatment I assume - what has been your potassium lab value been running? (I guess back there wasn't the last question).

One thing I do know is you should not routinely suffer cramps. This should be a solvable problem.

The easiest dry weight evaluation is to first look for edema which would indicate an individual is a certain amount over dry weight. If I see edema in my shin and ankles I know I am 3KG or more over dry. Other people might notice waking up with a puffy face or area around the eyes. Around the knee. It does vary. Keeping track of this is very helpful because edema is only really a serious problem after it gets past a certain point - for me above three KG is where I believe a threshold is crossed (I weigh 85kg, I would think this threshold relates to dry weight). Anyone on dialysis should strive to know their body to the degree that they recognize this outward sign of fluid over load.

The next thing one can easily do to inform a dry weight evaluation requires an assistant. Lie down. Your neck veins should be visible. Sit up, still on the floor, legs straight out. Veins still visible but less pronounced. Stand up. Neck veins not visible. this would indicate that a person is at their dry weight. If you lie down and the veins are not visable that would indicate being below your dry weight. If you stand up and your neck veins are visible it would indicate being significantly above your dry weight.

Dr Agar just presented a very interesting topic  as a Webinar on Home Dialysis Central http://www.billpeckham.com/from_the_sharp_end_of_the/2008/07/today-is-webina.html unfortunately due to technical problems it is nearly unwatchable on the replay. If you can it is still worth watching - this requires registration and then start with slide 8 to skip 15 minutes of technical snafus at the start. Dr. Agar's explanation of the three fluid chambers in the body and their relationship to how you feel during and after dialysis is a key concept for anyone on dialysis to understand. He also has written papers which I have written about too (here http://www.billpeckham.com/from_the_sharp_end_of_the/2007/12/dr-agar-on-flui.html; here http://www.billpeckham.com/from_the_sharp_end_of_the/2007/12/more-on-fluid-a.html; here http://www.billpeckham.com/from_the_sharp_end_of_the/2007/12/p-cresol-an-unm.html; here http://www.billpeckham.com/from_the_sharp_end_of_the/2008/01/optimal-dialysi.html)

But as you say in your case something else seems to be going on. How does your blood pressure change over time - before dialysis, on off days, during treatment?

[cherpep]

Since March, when I started on 5x/week at home, I usually do not make urine.  On my days off, I produce a little.  I don't remember the exact numbers in potassium, but I have been running in the low end of the target. 

Last night was a bad night.  I took off 1.5 liters, bringing me to my dry weight.  I went down to the same weight the previous night without any problem.  Yesterday, I didn't eat much so I can't see that I would have gained weight.  Last night actually started off pretty good.  It was during the rinseback that I started cramping, around midnight.  It started in my right foot - the kind of cramping where you can actually see your foot twist unnaturally.  It moved into my ankle, then my calf.  My husband massaged a little, but I really didn't get any relief until I started walking - which is always difficult for me right after dialysis.  So, I get up, walk a little until I I see things going black, sit down until the cramping gets unbearable, walk a little until things start going black, etc.  After a little while, my left leg began to cramp too.  The cramping continued all night.  I would finally fall asleep, and then one of my legs would get a severe cramp - usually in the calf.  The only thing I can do is get up and walk until eventually the cramping subsides.  Around 1:30am, I drank a bottle of water and ate a tomato.  I can't tell you how much walking I did last night, I think I wore holes in the carpet.  I can tell you that I only got about 2 hours of sleep total - then I had to get ready for work.  They cramped as I walked up the stairs, as I got into the shower, and even as I walked into work.  They are still twitching now, but it's been a couple of hours since the severe cramping.

I just don't know what else to do.  The doctors are baffled.  I'm gonna try raising my dry weight again, and use your methods to see if I still have any fluid.

[Roadrunner]

Hi,

I have two suggestions.  One comes from when I had leg cramps when pregnant - so many years ago.  My doctor told me to stand arm length away from the wall and then bend my arms till my head touched the wall and hold for the count of 20.  This stretched the leg muscles and helped keep the cramps away.  Don't know if this helps in dialysis but it easy enough to try before each treatment.

The second is something I read and seems to help my husband.  Don't eat salt before dialysis.  Salt retains water. 
Hubby says salt is holding on to the water and dialysis is trying to pull it off and you are in the middle of the tug of war.   

[cherpep]

Well, today is Wednesday.  I haven't had any cramping since that bad night last Thursday.  I have my fingers crossed & am knocking on wood.  I took the advice from another thread and am turning my UF rate up during the first hour, then turning it down for the remainder of the treatment.  It seems to be working for me so far.  Here's hoping it continues!!!!

[monrein]

The "ramping" of the UF rate works for me too.  Hoping this will provide a lasting solution.

[cherpep]

I pushed it a bit last night, my husband was very nervous.  It's just as hard on him as it is for me when that cramping starts.  He feels so helpless to see me in such pain.  Sometimes, he's in tears too.  Anyhow, I went below my dry weight last night.  I've been trying to lose weight and have been getting discouraged that I would cramp, even at my dry weight.  I have been extremely careful in what I've been eating, and really should have been losing weight.  Anyhow, I went .5 liter under my dry weight last night, and still no cramps!!!  So far, turning that UF up during the first hour is really working for me.  Plus, I feel great!!  I don't remember the last time I had this much energy.  I'm pretty excited about this. 

[monrein]

Excellent news Cherpep.

[cherpep]

I took off more fluid last night than ever before!!  I've always crashed if I took off more than 2 liters, even if I was 3 liters over my dry weight.  I skipped an extra day this weekend while we were camping, so I had a lot of extra fluid.  I took off 3.2 liters last night - without 1 cramp!! I turned the UF rate up during the first hour, so that more than half of it was removed during that time.  Then, I turned it down for the remainder of the treatment.  This definitely seems to be the answer to my cramping problem.  How great it is that I have control over this and have finally found a solution to those severe, painful, cramps!  IHD to the rescue again!  This site rocks!