I Hate Dialysis Message Board
Dialysis Discussion => Dialysis: General Discussion => Topic started by: iolaire on August 16, 2016, 04:58:14 AM
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My Kt/V has been declining for the past two years or so. I’ve been on dialysis for 3.5 years. At the start it was close to 2 at times. But it slid at some point and now the center has a hard time keeping it over 1.2 as required. My last lab work Kt/V was 0.78 so they increased the pump speed to 450 and moved me from a disposable #15 filter to the #17. Last year sometime they increased the ?distillate flow? (sorry could be wrong on what that measure is) from 500 to 600 to get better filtering.
This Kt/V test is one where they collect the blood before and after treatment.
My fistula has good blood flow, sometime early this year I had it check out because of the low Kt/V (my choice) and they took a look with the ultrasound and also on the table with the more advanced imaging and didn’t do anything saying the flow was great.
I’ve lost about 5 kg well on dialysis and am on 3.5 hours @ 88 kg. I have residual kidney function, urinate and think my kidneys still help to clear some of the minerals. I’m still healthy and have a good bit of energy (except on weekends when the heat index is 105*).
So that leads me to wonder if the change in Kt/V could reflect a change in kidney function. i.e. early on my kidneys were helping more - would that have resulted in higher Kt/V, versus today they might be helping less?
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My Kt/V has been declining for the past two years or so. I’ve been on dialysis for 3.5 years. At the start it was close to 2 at times. But it slid at some point and now the center has a hard time keeping it over 1.2 as required. My last lab work Kt/V was 0.78 so they increased the pump speed to 450 and moved me from a disposable #15 filter to the #17. Last year sometime they increased the ?distillate flow? (sorry could be wrong on what that measure is) from 500 to 600 to get better filtering.
This Kt/V test is one where they collect the blood before and after treatment.
My fistula has good blood flow, sometime early this year I had it check out because of the low Kt/V (my choice) and they took a look with the ultrasound and also on the table with the more advanced imaging and didn’t do anything saying the flow was great.
I’ve lost about 5 kg well on dialysis and am on 3.5 hours @ 88 kg. I have residual kidney function, urinate and think my kidneys still help to clear some of the minerals. I’m still healthy and have a good bit of energy (except on weekends when the heat index is 105*).
So that leads me to wonder if the change in Kt/V could reflect a change in kidney function. i.e. early on my kidneys were helping more - would that have resulted in higher Kt/V, versus today they might be helping less?
Your gradual loss over time of residual kidney funtion, resulting in no longer getting toxin clearances, and at only 3.5 hours per treatment x 3 weekly, there's a good chance you are being underdialyzed. Kt/V is a lousy indicator of whether or not someone is getting good diaysis treatment. Urea is an easy, non-toxic over time large molecule to cleanse from the blood system and causes less damage to the body overall. Kt/V does not allow for the harder to clear middle size molecules like phosphorous and B-2 microglobulin which play a greater role in dialysis patient health and long-term survivability. The AMOUNT OF TIME spent on the machine as opposed to how fast the blood is cleansed is a better determinate of good dialysis. I suggest you read (or maybe reread) about the Hemodialysis Product (HDP) , the work of two of dialysis pioneers, Belding Scribner, MD and Dimitrios G. Oreopoulos, MD, and currently espoused by world renown nephrologist, John Agar, MD, as a better indicator for good dialysis than Kt/V. At "just" 3 years on dialysis with some residual function, you haven't yet exhibited the complications of phosphorus and B-2M buildup in the body.
Belding H. Scribner, MD; Dimitrios G. Oreopoulos, MD
The Hemodialysis Product
(HDP): A Better Index of
Dialysis Adequacy than Kt/V
In a recent issue of this journal, Dr. Peter Blake and others commented on the ADEMEX (Adequacy of Peritoneal Dialysis in Mexico) study, a brilliantly planned and conducted study on the influence of increases in Kt/V on the outcome
of anuric continuous ambulatory peritoneal dialysis (CAPD) patients in Mexico. This prospective, controlled studywas presented at the recent meeting of the International Society for Peritoneal Dialysis (Montreal, June 2001), but has not yet been published. The results were clear-cut and highly significant. Specifically, they demonstrated thatincreasing the dose of CAPD—as measured by Kt/V and weekly creatinine clearance— among anuric CAPD patients had no effect on patient survival when compared to a control group on a lower dose of dialysis. This result provides additional evidence that Kt/V is a flawed concept upon which to base the dose of dialysis in general. The prime example that Kt/V is flawed is that it fosters short hemodialysis, which is inefficient in removing toxic middle molecules. Short hemodialysis may give a false impression of highly efficient hemodialysis by removing fast-diffusing urea and, thus, resulting in a high Kt/V. However, removal of toxic middle molecules and PO4, which dialyzes like a middle molecule, is reduced because of the shortened time. Short hemodialysis sessions have great appeal only to the uninformed dialysis patient and to for-profit dialysis centers. (my emphasis).
For the last three decades worldwide, but especially in the U.S.A., belief among the hemodialysis community in the reliability of Kt/V, combined with the natural desire of the patient to have the shortest possible time on dialysis, has resulted in the underdialysis of the vast majority of hemodialysis patients.
Validating the Middle Molecule Hypothesis
For decades, it has been abundantly clear that many important uremic toxins have a much largermolecular weight than does urea. The first hint of this came in Seattle during the early 1960s when Scribner observed that patients on chronic peritoneal dialysis seemed to be healthier than hemodialysis patients, despite less dialysis (as measured by creatinine clearance).3 This, in turn,led to the brilliant formulation by Babb of the middle molecule (MM) hypothesis.4,5
Out of this formulation, Babb et al. predicted that the peritoneum cleared MMs better than did the early dialysis membranes, which proved to be the case.6 Despite this finding, the improved well-being of the early Seattle PD patients may have been due, in part, to better preserved residual renal function, as Bargman et al. recently pointed out.7 The ADEMEX study provides further support for the much ignored MM hypothesis by demonstrating that the techniques that lead to increased urea removal did not improve patient health and well-being; rather, they caused harm to the CAPD patients due to increased exchange volumes. If the authors had followed a middle molecule marker during the study, perhaps they could have predicted the outcome long before the study was completed. There is irrefutable support for the conclusion that it is the adequate removal of middle molecules, rather than the removal of urea,,that correlates with survival and well-being among patients on hemodialysis. An important part of this evidence comes from the results obtained from more than 1,000 patients studied over the past 30 years in the dialysis program in Tassin, France,8-12 where the survival of HD patients is the best in the world. These results correlate
with middle molecule removal as measured by the dialysis index,5 but notwith Kt/V.8-12 Nonetheless—for reasons that remain unexplained—the world hemodialysis community, especially in the U.S., has for two decades continued
to ignore the spectacular results obtained in Tassin.
The Hemodialysis Product
Based on published evidence from many sources, we propose a new index of adequacy of hemodialysis, to be called the Hemodialysis Product (HDP). This new index incorporates dialysis frequency,
which is an important variable:
HDP = (hrs/dialysis session) x (sessions/wk)2
Table I lists various values of the
HDP for average-sized adults, as well
as the corresponding expected clinical
results. Since the HDP does not take
patient size into account, large adults
will require a higher HDP, especially
in the critical range below 60.
By incorporating dialysis frequency,
the HDP takes into account the very
positive results that have been obtained
with more frequent dialysis by De Palma,
13 Buoncristiani,14 Bonomini,15 Pierratos,
16 and Lockridge.17 Again, for reasons
unknown, these remarkable results
have been largely ignored by the U.S.
hemodialysis community, which still
bases its definition of minimum adequate
dialysis on a Kt/V = 1.2 per dialysis
3x/wk. Even at the latest National
Institutes of Health (NIH) conference
on this subject last April, the conferees
chose to defer action for several years
until yet another NIH-sponsored national
study can provide “evidence-based
results” that it is worthwhile to increase
the dose of dialysis.
The HDP is a simple-to-comprehend
index that already has been validated. A
key example is the value of 3x/wk for 8
hours = 72. This entry represents the 30-
year Tassin survival experience, which is
the best in the world.8-12 As for the lower
values in Table I, the corresponding high
incidence of malnutrition and death2
provides the validation that these low
values represent inadequate dialysis.
Validation of the efficacy of the higher
values, largely ignored until recently, has
been going on for decades.
Full article: http://www.therenalnetwork.org/qi/resources/HDP.pdf
And, this analysis from long-term dialysis consumer and patient advocate, Pater Laird, MD
Vindication for the Hemodialysis Product
By Peter Laird, MD
RenalWeb's Gary Peterson posted a recent article that in many ways is a vindication of the HemoDialysis Product proposed several years ago by Dr. Scribner and Dr. Oreopoulos in an article titled: The Hemodialysis Product (HDP) A better index of dialysis Adequacy than Kt/V.
The underlying premise for the HDP is Babb's Middle Molecule theory of dialysis which is not accounted for by the Kt/V concept of adequacy. Scribner and Oreopoulos argued that the Kt/V measurement is inadequate in that it only deals with the fast diffusing urea, arguably a nontoxic molecule, and it fails to take into account time dependent molecules such as B-2 microglobulin and phosphorus which acts like a middle molecule.
Removal of these time dependent middle molecules depends on the duration of exposure to the dialysis membrane. Removal is independent of blood flow rates, ultrafiltration rates and even, to an extent, the clearance rates of the artificial kidney. Time is the key variable and this is what allows for the elegant simplicity of the HDP.
HDP = (hours of dialysis per session) x (sessions per week)2
However, despite the theoretically application of the Hemodialysis product as a measure in support of the Middle Molecule time and frequency dependent theory, it never caught on in the dialysis community and in fact was widely rejected for the widely used Kt/V adequacy measurement. However, a recent article in Hemodialysis International by Kjellstrand, et, al brings the Hemodialysis Product back to the forefront of dialysis measurements:
Survival with short-daily hemodialysis: Association of time, site, and dose of dialysis
Short-daily hemodialysis can be too short. In this series of patients, every extra hour spent on dialysis was associated with better survival. This finding is in agreement with those of others analyzing thrice-weekly dialysis and interestingly is seen in patients treated by long night hemodialysis, where the weekly dialysis hours are 2 to 4 times long than in our patients on SDHD.
The dose of dialysis as expressed by Kt/V was not associated with survival. This finding is in agreement with similar results reported in patients on long-nightly dialysis. I has to be tempered with the fact that theses daily hemodialysis patients, except for 2, had weekly stdKt/V of 2 or higher and almost one-third had a Kt/V of 3, much above that recommend Kt/V of 2, to for "adequate dialysis" in the United States. Particularly in the United States, Kt/V, while reasonable to compare dialyzer efficiency, has taken too much precedence over the fact that a very important role of the kidneys is to maintain homeostasis. . .
We have over forty years of experience with SDHD with all of the studies revealing more frequent and longer weekly duration of dialysis reduces morbidity and mortality as well as promoting patient rehabilitation. The goal of the pioneers of dialysis was quite simple, to render a fatal disease treatable at last and to return the patient back to a productive life. The greed based, American style, short, rapid and violent hemodialysis sessions as practiced in the majority of incenter dialysis units is the cause of our excessive mortality in the last three decades as compared to Japanese, European and Australian/New Zealand providers that offer longer duration dialysis as the common standard.
It is time to put Kt/V into its proper perspective and adopt instead the Scribner/Oreopoulos Hemodialysis Product as our basic objective measure in combination with the most important measure of all, rehabilitation of the dialysis patient. Time and time again, the practices of the dialysis pioneers with longer sessions in the comfort of the patients home is the only manner in which America shall once again mitigate the shame of our excessive mortality rate among dialysis patients. Indeed, it is not only the excessive mortality rate that cries out to us from studies such as this, but the loss of quality of life that could easily be restored within the framework of "cost effectiveness" in the savings from preventing the prevalent complications of dialysis. The spirit of Dr. Scribner sounds out loud and true to do that which is right and just for our patients.
http://www.billpeckham.com/from_the_sharp_end_of_the/2010/09/vindication-for-the-hemodialysis-product.html
Bottom line - advocate for better dialysis or go for a transplant.
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Mine declined twice in the last three years, first I went from 4 hours to 4hours 15 minutes, then the next decline I went to 4hours and 30 minutes.
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My friend Kt/v at 0.78 spells insufficient dialysis. Mine average 2>. Ask your Neph. to help since you are very concerned.
I use Gambro Revaclear h 300 dialyzer 3hrs. x 3days/wk.
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To piggy back on the excellent thorough response here, more frequent dialysis is probably what is needed. I know that is the last thing a person on dialysis wants to hear. That's why I chose to do hemodialysis at home. So I have control over how much time and how many days. Although three days a week is standard for in center, that is not necessarily what is best for a person. Toxins and fluids build up on days off. And more frequent home hemo is gentler on the body and prevents the toxin and fluid build up, especially on the weekends. Five or six days a week provides adequate dialysis. Also less washed out feeling doing it at home.
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Thanks for the reminder for a follow-up here. I had a little bit of angioplasty on my wrist before it gets to my fistula where it was thinning a bit and at the same time we flipped the needles so they face away from each other. Those changes got my kt/v to about 1.4 with the high 450 pump speed, since I asked to move back to 400 and if it don't make labs next round I will accept some more time on the machine.
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My Kt/V is 4.5 I do 8 hours 3x a week incenter Nocturnal. I think more frequent is probably better but I don't want to turn my home into a hospital.
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I still feel like my remaining kidney function is helping me along. If I start really being impacted beyond lab numbers (PTH right now) I would consider home dialysis but really I'm hoping on a new kidney first...
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Five or six days a week provides adequate dialysis. Also less washed out feeling doing it at home.
You have more leeway to set up your home area the way you like it, so you can more comfortably while away the time while you dialyze. You will also never had to deal with an extra hour in the waiting room because things got backed up at the clinic, turning you 4 hour session (4.5 with pre and post treatment activity) into 5.5 hours or so.
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turning you 4 hour session (4.5 with pre and post treatment activity) into 5.5 hours or so.
Maybe it's different with Nxstage but here in Canada with Baxter 4 hour home dialysis session is never shorter than 5 hours. 45 minutes to set up and prime, then 15 minutes to take down and clean (I'm not including the hour or so the machine does it's self clean). And that's if everything goes smoothly.
But at least with home hemo you can choose your treatment time.
The main unit of our local hospital (the only place where one can get dialysis here) just started something so terrible I am just writing a letter of complaint. He's had to go back there for a bit here and there since his bypass surgery. He's not on their rotation so they are fitting him in where they can. Last night he was scheduled at 7:00, but didn't get started until 7:45. They took him off at 10:15 so he only got 2.5 hours. They have a new rule no overtime past 11pm so they ensure they get everyone off by 10:15 so they can clean up before they go home. So that's it for Sat, Sun, Mon, Tues and Wed. 2.5 hours of dialysis. He has regular session in the home hemo unit in the hospital Thursday and Friday at 7:30am. This Thursday happens to be his regular checkup (done every two months) Guess how shittly his labs are going to be then. This time it's all on them. He left Toronto at 1.5ks under his dry weight with potassium, phos, in check and the lowest creatinine I've ever seen.