Trying to understand this logic

[cdwbrooklyn]

What is the different with one patient doing dialysis for 3-4 hours and another one doing dialysis for 6-8 hours 3-6 days a week as long as the patients are getting good results.

If patient one do dialysis for 3-4 hours one day and patient two do dialysis for 6-8 hours the same day and they both decide to eat the same foods the next day, would patient one blood be less toxic than patient two blood? So, why seat on the machine for 6-8 hours if 3-4 hours work just as good? 
I'm just trying to get a clear understanding as I am very confused about all this short-term and long-term, in-center and home dialysis.  It's what works for the patient.  Every patient has different needs.   

Also, if short-term dialysis is not good for a patent's heart, what make long-term dialysis any better.  I would think that the longer you dialysis the more it will effect your heart because of the blood flowing in and out your heart for so long. 

Just my opinion; don't judge me but do voice your opinion.  Also, don't state what you are not doing.  Speak about the dialysis you or who you care for is doing.  I don't want to hear about something you never tried before or  based on some article you read. 

[Hemodoc]

Let's look at some issues from a historical perspective. Clyde Shields was the first chronic dialysis patient using the Scribner shunt. and he lived for nearly 10 years on very primitive dialysis equipment. In the 1960's, they adopted a schedule of thrice weekly 6-8 hour sessions with excellent results despite the antiquated machines.

In the 1970's, after the ESRD program came under the control of the Federal government through Medicare,  CMS instituted a payment structure that greatly hindered home dialysis. The overwhelming majority of patients were cared for in-center. The largest dialysis provider, National Medical Care was quite corrupt and greedy as documented not only in the media, but in court records as well. Fresenius merged with them in the late 1990's with many of their officers who remained.

Shortly after the ESRD program funding by the Feds, dialysis researchers began looking at "ultra-short" dialysis schedules. These were 3-4 hour sessions. These studies culminated in one study that "showed" TIME on dialysis was less important than clearing small urea molecules. An offshoot of that study was the development of the Kt/V as a measure of dialysis adequacy. Only America bought into this measurement. The rest of the western nations already understood the importance of time on dialysis as an important predictor of survival. Soon, a large gap developed between the United States and these other western nations as our patients became sicker and died sooner. Since the 1980's many well known advocates for optimal dialysis have waged war with the corporate greed of American dialysis companies to provide physiologic treatments.  America sadly has had twice the mortality rates in our dialysis units when compared to Japan which has the best outcomes in the entire world.

In short, much research confirms that the increased frequency and length of treatment with dialysis directly results in better outcomes. The issue is removing fluid more so than removal of urea which most believe is a non-toxic molecule.  The average person has 5 liters of blood in their circulatory system. If you go into dialysis and remove 4 liters of fluid very rapidly, several things happen. First, the fluid in the blood, called plasma, is removed rapidly which places strain on the heart. Many studies now reveal that the heart suffers damage directly to the muscle in this situation. Blood pressure falls and there is reduced blood flow to the heart leading to a condition called ischemia which is lack of adequate oxygen to the heart muscles. Enzymes we measure for heart attack patients rise during this type of dialysis. On the other hand, the fluid that is in the tissues such as the swelling seen in the legs does not get back into the arteries and veins fast enough to prevent the low blood pressure and other symptoms such as cramping, nausea, vomiting, dizziness and passing out.

The only solution is to take the fluid off more frequently so you can take off a smaller volume and slower.  That is why the 6-8 treatments are healthier for the heart. Most people that perform extended dialysis of 6-8 hours do it while sleeping at night.

So, I would simply state that the outcomes between 3-4 hour sessions and 6-8 hours sessions are not at all the same as you contend in your post. For every 30minutes of added dialysis, you significantly improve survival chances. Fluid removal is perhaps the most important aspect of survival.

Another aspect of longer and more frequent dialysis is removal of what is called "middle molecules." These are molecules that cause inflammation in the body and their removal is TIME dependent. That is the basic theory behind more frequent and longer duration dialysis and why it is indeed better for the heart.

I hope this helps and please don't hesitate to ask about any of this that may not be clear.

Take care,

Peter

[obsidianom]

What is the different with one patient doing dialysis for 3-4 hours and another one doing dialysis for 6-8 hours 3-6 days a week as long as the patients are getting good results.

If patient one do dialysis for 3-4 hours one day and patient two do dialysis for 6-8 hours the same day and they both decide to eat the same foods the next day, would patient one blood be less toxic than patient two blood? So, why seat on the machine for 6-8 hours if 3-4 hours work just as good? 
I'm just trying to get a clear understanding as I am very confused about all this short-term and long-term, in-center and home dialysis.  It's what works for the patient.  Every patient has different needs.   

Also, if short-term dialysis is not good for a patent's heart, what make long-term dialysis any better.  I would think that the longer you dialysis the more it will effect your heart because of the blood flowing in and out your heart for so long. 

Just my opinion; don't judge me but do voice your opinion.  Also, don't state what you are not doing.  Speak about the dialysis you or who you care for is doing.  I don't want to hear about something you never tried before or  based on some article you read.

What Peter wrote is all true and accurate. I would like to just add the following.
Dr. Agar in Australia has written about the requirement for 10% of total time on the machine as the minimum treatment for dialysis. That would come out to about 17 hours per week. That is what I try to go for with my wife. WE do 5 days per week for 3.25 plus hours per treatment.  It works out to just about 17 hours weekly. That is with Nxstage. So shorter but more frequent dialysis can work well too.
This would allow slow removal of fluid if you do remove fluid(we dont) and not stun the heart with rapid fluid removal. AS our nephrologist said when he came back from dealing with a patient they had just crashed in the dialysis unit on a Monday after 2 days off dialysis , "that wont happen to you at home ". They have to take off fluid too fast. We dont at home doing 5 days per week. The other option as Peter wrote is longer time per session to take off fluid. In the end , both work.

[noahvale]

*

[cdwbrooklyn]

What is the different with one patient doing dialysis for 3-4 hours and another one doing dialysis for 6-8 hours 3-6 days a week as long as the patients are getting good results.

If patient one do dialysis for 3-4 hours one day and patient two do dialysis for 6-8 hours the same day and they both decide to eat the same foods the next day, would patient one blood be less toxic than patient two blood? So, why seat on the machine for 6-8 hours if 3-4 hours work just as good? 
I'm just trying to get a clear understanding as I am very confused about all this short-term and long-term, in-center and home dialysis.  It's what works for the patient.  Every patient has different needs.   

Also, if short-term dialysis is not good for a patent's heart, what make long-term dialysis any better.  I would think that the longer you dialysis the more it will effect your heart because of the blood flowing in and out your heart for so long. 

Just my opinion; don't judge me but do voice your opinion.  Also, don't state what you are not doing.  Speak about the dialysis you or who you care for is doing.  I don't want to hear about something you never tried before or  based on some article you read.

What Peter wrote is all true and accurate. I would like to just add the following.
Dr. Agar in Australia has written about the requirement for 10% of total time on the machine as the minimum treatment for dialysis. That would come out to about 17 hours per week. That is what I try to go for with my wife. WE do 5 days per week for 3.25 plus hours per treatment.  It works out to just about 17 hours weekly. That is with Nxstage. So shorter but more frequent dialysis can work well too.
This would allow slow removal of fluid if you do remove fluid(we dont) and not stun the heart with rapid fluid removal. AS our nephrologist said when he came back from dealing with a patient they had just crashed in the dialysis unit on a Monday after 2 days off dialysis , "that wont happen to you at home ". They have to take off fluid too fast. We dont at home doing 5 days per week. The other option as Peter wrote is longer time per session to take off fluid. In the end , both work.

That's what I'm talking about.  I can understand the 17 hours time. 

If my doctor order me to do 500 blood flow, 30L, at 2 ½ hours but I decided that I want to go slower so I do 400 blood flow, 30L at 3 ½ hours, do I get the same results? 

Sometimes I will do 450 blood flow, 30L at  3 hours 10 minutes and I find that the clearance is almost the same should I decided to do it faster.    I do understand the heart and fluid removal but some people hearts can take the 500 blood flow.  If I’m not mistaking, a person on this site I believe posted that he or she has a 600 blood flow.  I was amazed because I though it just stops at 500.   If it was not this site, it was a site I was on.  I’m not really should which site but I do remember seeing it.   

Thanks for your reponse.

[cdwbrooklyn]

Let's look at some issues from a historical perspective. Clyde Shields was the first chronic dialysis patient using the Scribner shunt. and he lived for nearly 10 years on very primitive dialysis equipment. In the 1960's, they adopted a schedule of thrice weekly 6-8 hour sessions with excellent results despite the antiquated machines.

In the 1970's, after the ESRD program came under the control of the Federal government through Medicare,  CMS instituted a payment structure that greatly hindered home dialysis. The overwhelming majority of patients were cared for in-center. The largest dialysis provider, National Medical Care was quite corrupt and greedy as documented not only in the media, but in court records as well. Fresenius merged with them in the late 1990's with many of their officers who remained.

Shortly after the ESRD program funding by the Feds, dialysis researchers began looking at "ultra-short" dialysis schedules. These were 3-4 hour sessions. These studies culminated in one study that "showed" TIME on dialysis was less important than clearing small urea molecules. An offshoot of that study was the development of the Kt/V as a measure of dialysis adequacy. Only America bought into this measurement. The rest of the western nations already understood the importance of time on dialysis as an important predictor of survival. Soon, a large gap developed between the United States and these other western nations as our patients became sicker and died sooner. Since the 1980's many well known advocates for optimal dialysis have waged war with the corporate greed of American dialysis companies to provide physiologic treatments.  America sadly has had twice the mortality rates in our dialysis units when compared to Japan which has the best outcomes in the entire world.

In short, much research confirms that the increased frequency and length of treatment with dialysis directly results in better outcomes. The issue is removing fluid more so than removal of urea which most believe is a non-toxic molecule.  The average person has 5 liters of blood in their circulatory system. If you go into dialysis and remove 4 liters of fluid very rapidly, several things happen. First, the fluid in the blood, called plasma, is removed rapidly which places strain on the heart. Many studies now reveal that the heart suffers damage directly to the muscle in this situation. Blood pressure falls and there is reduced blood flow to the heart leading to a condition called ischemia which is lack of adequate oxygen to the heart muscles. Enzymes we measure for heart attack patients rise during this type of dialysis. On the other hand, the fluid that is in the tissues such as the swelling seen in the legs does not get back into the arteries and veins fast enough to prevent the low blood pressure and other symptoms such as cramping, nausea, vomiting, dizziness and passing out.

The only solution is to take the fluid off more frequently so you can take off a smaller volume and slower.  That is why the 6-8 treatments are healthier for the heart. Most people that perform extended dialysis of 6-8 hours do it while sleeping at night.

So, I would simply state that the outcomes between 3-4 hour sessions and 6-8 hours sessions are not at all the same as you contend in your post. For every 30minutes of added dialysis, you significantly improve survival chances. Fluid removal is perhaps the most important aspect of survival.

Another aspect of longer and more frequent dialysis is removal of what is called "middle molecules." These are molecules that cause inflammation in the body and their removal is TIME dependent. That is the basic theory behind more frequent and longer duration dialysis and why it is indeed better for the heart.

I hope this helps and please don't hesitate to ask about any of this that may not be clear.

Take care,

Peter

Thanks Peter for your response.  I did read your post but I was really tired at the time.  However did the machines changed since 1970, 1980, and 1990?  I know back in the days doing dialysis was more difficult than nowadays.  I use the Pure Flow System One machine which is fairly new in New York.  Compare to the other machines, this is the best so far.  I do understand the time but sleeping on the machine for six - eight hours is a little too much for me.  I don't sleep in my bed when I dialysis, I sleep on my decliner and I wake up very 1/2 hours which don't allow me to sleep very well.  Imaging six - eight hours for me, I will not get any sleep at all.   Anyhoo, thanks for the education.

[Hemodoc]

Your urea clearances will be exactly the same. However, your more important or actually the most important clearances will improve.

I run 40 liter for about 4.35 hours 5 days a week and I would like higher volumes but the sodium levels are too high for me.

As far as blood pump speeds, I run at 350 blood flow with 45% FF. The high blood flows can damage your fistula. Japan runs about 250 ml/min and that is for their in-center patients and they have the best survival in the world. It is not about removing urea that matters with dialysis, but TIME on the machine even at slow pump speeds according to many national and international studies.

I hope this helpful to you to bring back to your medical team, but a pump speed of 500 for blood flow scares me to death for what it can do to the access.

[cdwbrooklyn]

CDWBrooklynn - Coming from his prespective, Hemodoc covers your issues very well.  And, Obs tells you what he does for his wife and why.  However, are these responses what you are needing?

Not really, I just wanted to know the difference when it comes to dialysis.  Everyone is different and what works for one person may not work for everybody.  However, I am glad that I am getting some background education so I can make a better choice for my further. 

Thanks.

[cdwbrooklyn]

Your urea clearances will be exactly the same. However, your more important or actually the most important clearances will improve.

I run 40 liter for about 4.35 hours 5 days a week and I would like higher volumes but the sodium levels are too high for me.

As far as blood pump speeds, I run at 350 blood flow with 45% FF. The high blood flows can damage your fistula. Japan runs about 250 ml/min and that is for their in-center patients and they have the best survival in the world. It is not about removing urea that matters with dialysis, but TIME on the machine even at slow pump speeds according to many national and international studies.

I hope this helpful to you to bring back to your medical team, but a pump speed of 500 for blood flow scares me to death for what it can do to the access.

You could be right about that pump speed effecting your access.  I have buttonholes and I am having some problems with the pump speed.  It now allows me to run at 450 for 1 1/2 before the numbers start to decrease otherwise the numbers will increase and the alarm goes off.   However, my clearance somedays 84 and most days 83. 

[Hemodoc]

I believe the "clearance" you are talking about is blood processed when you refer to the 83 an 84  and that is in liters. In other words, that number is how many times your blood is passed through the machine which is about 18 times if you have an average of 5 liters in circulation.

As far as running at those speeds, that is not how they do dialysis in Japan and Australia and other western nations. This is a uniquely American style dialysis to be as short and fast as possible. This is the exact opposite of what we know works best with the best outcomes. Once again, I run at 350 and do about 4:22 with each session.

Perhaps running some of these questions by Dr. Agar at Home DIalysis Central on their ask the experts site would give you more perspective of how they do dialysis in Australia. He is very receptive to questions, especially us abused American patients. This is an American issue, not a dialysis issue.

[Bungarian]

At my place the only reason they run people 5 or 6 hours is to take off extra fluid. One guy who cannot control what he drinks does it a lot.

[jeannea]

I would add that comparing patients 1 and 2 isn't all that helpful. Your dialysis needs can really vary based on your type of kidney disease and any other diseases you have. Also, some patients have no residual kidney function and some do. I will say that the patient who pays attention to his diet and medicines and other instructions does better than the patient who says screw it.

[obsidianom]

Your urea clearances will be exactly the same. However, your more important or actually the most important clearances will improve.

I run 40 liter for about 4.35 hours 5 days a week and I would like higher volumes but the sodium levels are too high for me.

As far as blood pump speeds, I run at 350 blood flow with 45% FF. The high blood flows can damage your fistula. Japan runs about 250 ml/min and that is for their in-center patients and they have the best survival in the world. It is not about removing urea that matters with dialysis, but TIME on the machine even at slow pump speeds according to many national and international studies.

I hope this helpful to you to bring back to your medical team, but a pump speed of 500 for blood flow scares me to death for what it can do to the access.

Why do you push it until it alarms?  Your blood speed is so high that little by little you could be damaging the fistula lining permanently. One of the engineers at Nxstage was discussing this with me . he has seen directly in his work how the lining of the fistula is effected by high venous flow/speed . It causes serious changes to the lining . It creates serious turbulance. I agreee with Hemodoc that 350 or lower is safe, above that is bad news for the fistula over time.

You could be right about that pump speed effecting your access.  I have buttonholes and I am having some problems with the pump speed.  It now allows me to run at 450 for 1 1/2 before the numbers start to decrease otherwise the numbers will increase and the alarm goes off.   However, my clearance somedays 84 and most days 83.

[obsidianom]

Why do you push it until it alarms?  Your blood speed is so high that little by little you could be damaging the fistula lining permanently. One of the engineers at Nxstage was discussing this with me . he has seen directly in his work how the lining of the fistula is effected by high venous flow/speed . It causes serious changes to the lining . It creates serious turbulance. I agreee with Hemodoc that 350 or lower is safe, above that is bad news for the fistula over time.
Nxstage isnt designed to use blood speed as the indicator of amount of dialysis. It is the VOLUME of dialysate that is key with time on machine second in importance. High blood speeds gain little on Nxstage.

[PrimeTimer]

Question: If a dialysis patient wants to run a little longer for instance, do 4 hour tx opposed to 3 hr 39 mins, but not change their filtration (30 liters) how is the amount of Heparin decided? Pre-treatment or do you add more Heparin during treament? And of course, how much? I suppose the dose is something for the Neph or Nurse to decide or can patients do this themselves? My husband runs 5xweek for 3.50 treatments but we are thinking of sometimes doing 4 hours (not every day tho) and are concerned about clotting. 

Side Note: Hope you are doing well, cdwbrooklyn! Been awhile...hope you got your fistula all prettied back up and on to enjoying life again!   

[kristina]

I would add that comparing patients 1 and 2 isn't all that helpful. Your dialysis needs can really vary based on your type of kidney disease and any other diseases you have. Also, some patients have no residual kidney function and some do. I will say that the patient who pays attention to his diet and medicines and other instructions does better than the patient who says screw it.

Thanks jeannea for saying what I was going to mention ...
I still have some kidney-function and "despite" my needing dialysis, I still continue to "pamper" my kidney-function every single day
with a continuation of my kidney-friendly diet and I still do everything I possibly can do to keep my "two little fighters" functioning for as long as possible ...
... I also continue to keep as fit as I possibly can and I still go every day for my walk and during my dialysis-treatment I "do" once every hour gentle exercises
for up to 10 minutes every time, to make sure that my body does not "stiffen up" too much during my four hours of dialysis-treatment...
... Because of all this, I perhaps do not need as much dialysis-treatment as a person with no kidney function
and it is very important for me to pay attention and try to do the very best I can to assist my medical dialysis-team ... 
... I also make sure to keep my "grey cells" busy during every dialysis treatment with interesting books and/or crossword-puzzles,
to prevent myself from becoming too sad about my dialysis-situation...
Best wishes and good luck from Kristina.