Longer Treatments

[Hazmat35]

HELLO ALL! 

I've been on "D" for about 1 1/2 Years now.  At first, my dr. had me doing 4 hour treatments 3X per week.  Then since all my labs were good, he dropped it to 3 hour 45 minutures.  Then again a few months later to 3 1/2 hours per session. 

Since then all my labs have been wonderful, all blood test come back great, KT/V is always over 1.51, my potassium is always under 4.0.  I've never missed but one treatment in a year and a half. 

So, the other day, my doctor came to visit me at the center, looked at my chart, and said that he has noticed with patients that LONGER treatments are much better on the veins for the LONG TERM Dialysis patients and wants me to go back to 4hours per session. 

Does this sound right?  Or am I missing something?  I really don't want to go back to 4 hours, but if it's better for me in the long run, then I guess I'd be stupid not too! Right!!!!  Please advise! 

[jeannea]

From all my reading here, yes I understand that longer treatments are better for you. But I understand feeling sad. When I was on hemo I was so happy just to get told my treatments would be 15 minutes shorter. And yet other times I waste 15 minutes not even thinking about it. Hang in there. If it helps you, you can make it to 4 hours.

[boswife]

oh boy oh boy,, we have a discussion on this very thing going on on the nxStage site.  Theres so much to it all that it's really hard to say.  I'll say that it has been said that longer *slower* is always better.  And, that the 'extended' or nocturnal is the cadalac of treatments.  Part of the reason being that it takes a certain amt of time for some of the molicules to 'be available' for removal,(phos being one of those)  and 3 hours just doesnt accomidate that.  BUT... If your values havent changed, and your doing fine and feel good, then are they considering that your urin (if you still pee    ) could be taking care of that part and you can still coast on the shorter D?  We do D at home, and have lengthend hubbys treatment from perscribed speed and time by slowing down his blood flow rate.  Now, we're hearing that we still need some speed if we're going to only go an hour more and not the full 8 hours.  OUr whole purpose was to slow down things for heart and fistula safty so we're in a bit of a turmoil oursleves knowing exactly what to do. 

So, back to you.  If your values/numbers havent changed and you still feel well, i dont know what your answer would be.  It was a huge concern that the 'speed' of the incenter treatments was causing problems with heart and fistula so if they were going to lengthen your time so they could be 'gentler' on those, well, i'd say mabie you should feel good about their concern.  But,,,,then, would you still be getting as much clearance....  Ohhhh, i should probably not get you all wrapped up in ALL that as your question is probably a lot simpler than i make things out to be.  Bill P will hopfully come on and give you some insite.
Sorry if i've just confused you more

[Ang]

LONGER treatments are much better on the veins for the LONG TERM 

 
[/quote]
never really heard this one,sounds fishy to me.

as to longer treatments are better for you, thats 100% correct.

the longer the better

[jbeany]

Maybe that implies that the longer treatments are being run at lower pump speeds, which puts less pressure on the access.

[Bill Peckham]

I think the connection between longer and slower, and longer and better for the veins, is that longer necessarily means a lower UFR.

Over time there is tremendous benefit to keeping the rate at which water is removed during dialysis - the ultra filtration rate aka the UFR - below the rate at which water transfers from the intercellular space to the blood stream, ~ 400 to 700ml/hr   Slower dialysis, if one means a lower UFR, is very beneficial.

From there I think people have heard the word slower and assumed what was being described was a slower blood pump speed. Also  a lot of the time this language is used - longer and slower - as a way to explain the benefits of nocturnal treatments and as it happens it is very common to turn down the blood pump speed when doing nocturnal.

I think this is the logic chain: Long, slow dialysis is good. Nocturnal is long, slow dialysis. Nocturnal uses a lowered blood pump setting. Long slow dialysis means lowering the blood pump speed. Lowering the blood pump speed is good.

Where that goes wrong is linking the observation that nocturnal dialysis use a low blood pump speed (compared with conventional incenter) with the observation that nocturnal (or 8 hour runs any time of the day) are good. The benefit isn't due to the low blood pump speed, it comes in spite of the low blood pump speed.

HELLO ALL! 

I've been on "D" for about 1 1/2 Years now.  At first, my dr. had me doing 4 hour treatments 3X per week.  Then since all my labs were good, he dropped it to 3 hour 45 minutures.  Then again a few months later to 3 1/2 hours per session. 

Since then all my labs have been wonderful, all blood test come back great, KT/V is always over 1.51, my potassium is always under 4.0.  I've never missed but one treatment in a year and a half. 

So, the other day, my doctor came to visit me at the center, looked at my chart, and said that he has noticed with patients that LONGER treatments are much better on the veins for the LONG TERM Dialysis patients and wants me to go back to 4hours per session. 

Does this sound right?  Or am I missing something?  I really don't want to go back to 4 hours, but if it's better for me in the long run, then I guess I'd be stupid not too! Right!!!!  Please advise! 

Back in 1996, when I was using incenter dialysis, I requested that my time get increased from 4 hours to 4 hours and 45 minutes. It wasn't that four hours wasn't working - I was traveling and working and had good labs - it's that I thought I could feel even better. And indeed, when I increased the time I felt better. This same thing happened in 2001 when I increased frequency form 3x week to 6x. I was surprised again by how much better I felt. You can get very use to feeling poorly

So I think one thing to consider is that over time we loose track of what it means to feel well and we get use to how we are feeling. Then you increase your time or instead of having two days off you slip in an extra run each week, and suddenly you feel better and you realize that you didn't know how much of a handicap you were operating under at the lower dose.

Incenter you can increase your time without having to take into consideration how that changes things like your dialysate flow or blood pump speed. For those of us using NxStage changing our run length has implications for blood flow and dialysate flow so it can be complicated figuring out what will happen. Incenter that isn't a problem.  Increasing the run length will decrease UFR and increase removal of solutes. And that is good.

[PKDSTGV]

I'm new to all of this but to add to what has already been said, from what I understand each of our organ systems has their own clock.....just like we have our sleep/wake cycles. Dialysis works more efficiently if we provide it in a way that is MOST natural for the body and the body manages this process through the kidney's circadian rythmn. For humans, our kidneys are at peek performance when we are at rest which is why they've found nocturnal hemo to be such a good way to dialyze.

They've discovered this is the case for certain types of cancer and clinics are actually changing chemotherapy administration times to coincide with the internal clock of the organ involved.

So while slower IS better and longer IS better......you really see the benefits when you do it at night.  I hope this makes sense!!

[lmunchkin]

Outside of a transplant, I absolutely agree that nocturnal is the best way.  I would definately be doing J. on Nocturnal, but unfortunately I work everyday!  I do Nxstage on him and try to do no less than 3.5 hrs. Sometimes I get 4 hrs but I try to do it slower and longer!  It just makes sense to me.  I generally run a BFR around 400, but keep uf down low!

I am so amazed sometimes at how much better he feels.  We are content with what we have.

lmunchkin       

[jbeany]

So really, it needs to be longer, slower, and more frequently!

[Bill Peckham]

So really, it needs to be longer, slower, and more frequently!

The thing frequency does is keep down the amount of fluid gained between treatments. So you not only have a lower UFR from running longer, you also have less to remove from running more frequently. Very good for you circulatory system. Blood flow rate doesn't really come into play unless you want it to or are using NxStage.

[lmunchkin]

If J. is doing good on his labs and fluid control, I will run him 3 then off 2, but if he looks a little puffy ,then I do him 3 and off 1.  Believe it or not he is on 20L dialysate. Alot of people are on 30 or more.  I hope we can continue like this, but as we all know how Murphys Law goes!!

And I don't know if others doing nxstage does this or not, but I listen to his lungs, heart and all with a stethescope (not sure of spelling).  He has had no problems in over a year!  I know, we are so blessed to have the peace and quite right now in this Kidney world!

lmunchkin     

[boswife]

lmunch, how do you get to keep BFR at 400 and go that long?  We too are at 20L dialysate and running 3 1/2 hours but have lowered BFR to 310 to reach that time..  I am hoping Bo's kt/v is going to show good this time around as we are going longer, slower, but such a low BFR and now going 5 instead of 6 days a week.  I hate that they're going to base things on that kt/v. I so dont want to hear that it's not working and that they want us to go back to  6 days (his quality of life has to be considered,,,,he is soooooo happy with the 5 days and feels better)  I think if anything, upping the BFR would be the answer but then it shortens time... ugh  Heck, mabie it'll come out perfect huh


PS..... EXCELENT EXCELLENT EXCELLENT Bill!!  Thanks !! GREAT explanation!!

[RichardMEL]

Some great posts here have pretty much stolen my thunder on this - that longer is only "better" longer term if you go slower with the UFR (and pump speed) because it's less stress on the access point and veins in the body. Also if you do it more frequently the less fluid both remaining in the system between treatments, and the less that needs to be taken off is also less stress on the body - which is why you'd want it more frequently - and also to keep the overall level of toxins down.

Getting down to 3.5 hours is pretty remarkable. I was stuck on 5 hours for over 4 years.. they'd never take me lower, despite also very good labs - just because our lot prefer to run it longer and slower (I used a pump speed between 300 and 350) and usually had a UFR of 400 or less. It definitely lead to less crashes, cramps etc .. but more boredom!

[lmunchkin]

lmunch, how do you get to keep BFR at 400 and go that long?  We too are at 20L dialysate and running 3 1/2 hours but have lowered BFR to 310 to reach that time..  I am hoping Bo's kt/v is going to show good this time around as we are going longer, slower, but such a low BFR and now going 5 instead of 6 days a week.  I hate that they're going to base things on that kt/v. I so dont want to hear that it's not working and that they want us to go back to  6 days (his quality of life has to be considered,,,,he is soooooo happy with the 5 days and feels better)  I think if anything, upping the BFR would be the answer but then it shortens time... ugh  Heck, mabie it'll come out perfect huh

__________________________________________________________________________________________________________________
Boswife, I do all sorts of things to reach 3.5 hrs. but you are right at bfr of 400 it is hard to do and I have not done 3.5 hrs at that rate. That was an typing error on my part.  I meant 3.0 hrs!  Sorry! 

So glad to hear that Bo is doing 20L.  My J. doesnt want it increased at all, but if need be, I will do more if I have to!

Let me give you an example of what I ran him his 1st of 3days:  My husbands dry weight is around 179lbs (81.6)  He weighed 184 (83.6) before D.  By my calculations I had to remove 2.0
I set green at 6.2 yellow at 0.70 and bfr at 380

End of tx time: 3 hrs. 15 mins  Tot Dial: 20.0  Total UF: 2.0  BLP: 75

Weight at end of trmt: 179lbs (81.6)

Just as long as I get 3 hrs  or more with protecting his access, Im cool with it!  Like your Bo, my J does like having a 2 days off.  And I really believe that it tends to make them realize that what they consume "DOES MAKE A DIFFERENCE" so they do what is right for them, especially on their off days!

This is the Beauty of NxStage, aint it? It use to be him fighting to stay out of In-Center, but I got to tell ya, Im right there with him! Even if we have to go back to 5-6 days a week (ugh) we will to keep from going back to clinic!

What are the ranges your clinic requires on Ktv, Boswife?

lmunchkin   

P.S.  Yea I know it makes them happier!  You know they need a break from it too!  And we work hard to give it to them!!!   






EDITED: Fixed quote tag error - jbeany, Moderator

[boswife]

Ok lmunchkin...  First, our center (or nxStage?) wants 2.1 or greater.. How about yours or is that standard?

He gets 2.36-2.67 on the kt/v  (how about yours?)

heres his parimiters
wt           68.6
UF goal     .8
Uf rate      .33
Dialysate flow 5.6  (which is where it tops out at when the uf rate and BLP are set)
BFR  310
FF   32

end of treatment 
Total therapy time    326
Treatment volume     19 (* really 20)
total uf       .8
BLP             64

*(the treatment volume is actually 20 but i run out if we put it for 20 on bags or PF..it's my machine but i love it so we take that quirk)
You get much better BLP with your numbers. 

In discussion it seems we want that uf rate as low as we can for stability or ease on heart so dont know what to do about that.. and do you do some toggling to get that  Dialysate flow rate going after start of treatment??

[lmunchkin]

Well your treatments look very good to me.  The reasons my blood liters processed is higher, is because Im runing a higher BFR.  The NxStage nurse, and it makes sense in some ways, that BLP is one of the things they look at because it tells them how many liters of blood has run through the machine for cleansing!  Go figure!  Yes, I do have to toggle alot to get the desired time. My clinic allows me FF 29 to 33, so I have some leave way there, as you probably do also!  The lower the FF the longer the tx time!  ISNT IT NICE TO BE IN CONTROL OF THEIR TREATMENTS! I don't look at this (although I use to) like a job, I really look at it as a hobby!  Im really getting in to it and enjoying it too!

Now my Nxstage clinic  wants a Ktv of  .50, I don't understand the big difference in Numbers here!  Wonder if Greg 10 or someone else can chime in on this!  You reckon it has to do with body mass, cause there is quite a bit of weight difference in our hubbys.

Wow, I can't believe it is 12:00 here!  I got to get to bed!  Hopefully, someone can answer the question of KTV for us Boswife.
Night

lmunchkin