Fluid Overload :( Please read.

[alewis328]

I need some help from the experts. My D has been having major problems with fluid overload. Yes we are restricting fluid intake and sodium and all that. He is scheduled to go to his incenter dialysis at 6:45 tomorrow morning but I have learned from the past few weeks that the remainder of the time until he goes in may just be to much.  Fluid retention landed us back in the hospital on Friday. Where they did dialysis (later than they should have) and pulled off over 5 liters of fluid.  He is rapidly getting to be that overloaded again and when it starts to effect his breathing, I panic. I know he will not want to go back to the hospital, esp just for them to monitor him and do dialysis that is already scheduled for early tomorrow. (we have been there 5 times in the last month, for various reasons)
My question is - can anything be done today to help with the fluid retention?  Anything at all?  Just enough to keep him safe until the "challenge" his dry weight tomorrow at dialysis?
I appreciate any and all feedback.

[boswife]

I would try to get him in somewhere today.  Often another place will fit in someone with situations like that.  Better than a hospital stay.  We had one guy going 5x a week because he just held fluid.  Have you thought of home hemo??  Many of us here do that and it prety much solves that issue.  Im wishing you the best and hope someone else has better info.  Sorry, i know it's awful having to just sit and watch.  Oh, just a thought (if he still pee's) They once just had hubby take extra lasix and it did the trick. 

[Bill Peckham]

Is the unit using sodium modeling? Reading your post, the first thing that came to mind is D is being loaded with sodium at dialysis and then is sneaking fluid. This is something that happens far too often and the signs are just as you described: family/caregivers doing all they can to control sodium and fluid and the dialyzor coming in needing to take off +5kg each treatment.


One effect of this is guilt. The dialyzor feels like they're a failure for not being able to control their fluid intake, sneaking fluid at every turn. We must understand that thirst is not controllable through will power. It is a primal drive so before I do anything I would want to be sure that the unit's machines are correctly calibrated and they are not giving him excess sodium during the run.


Once that is assured I would expect the unit to provide 4 treatments a week under the medical justification of fluid overload. It is important to keep his fluid removal rate lower than what it sounds like they are using on him.


That much fluid gain given you diligence sounds exactly like sodium sabotage to me.

[alewis328]

I will be sure to ask them about the sodium thing tomorrow when I take him to dialysis. I am glad that it is a holiday and I will be off work. We have briefly thought of home hemo but I am just not sure and neither is he. He was on PD but has recently switched back to hemo.  The PD quit being effective for him.  They are thinking this could be due to peritoneal cavity failing. He also was very very sick when he was switched back to Hemo. Much vomiting, very dehydrated.  I believe this has caused problems with calculating his true dry weight. It is being challenged tomorrow also. Thank you for both your replies. I believe I will give him some more lasix (he normally take 120 mg, 3times per day) Do you think I should just give him an extra 120mg dose?  I also read on here about green tea maybe helping?  At this point I am willing to try anything.  he is so swollen and I know he is feeling horrible. Plus, the swelling in legs and feet kept him (and I) up almost all night, so he is exhausted now also.
We live in a very rural area.  Keeping the dialysis clinic open on the weekends would just seem absurd to those people! How dare anyone need emergency treatment on a weekend??? 

[Bill Peckham]

I will be sure to ask them about the sodium thing tomorrow when I take him to dialysis. I am glad that it is a holiday and I will be off work. We have briefly thought of home hemo but I am just not sure and neither is he. He was on PD but has recently switched back to hemo.  The PD quit being effective for him.  They are thinking this could be due to peritoneal cavity failing. He also was very very sick when he was switched back to Hemo. Much vomiting, very dehydrated.  I believe this has caused problems with calculating his true dry weight. It is being challenged tomorrow also. Thank you for both your replies. I believe I will give him some more lasix (he normally take 120 mg, 3times per day) Do you think I should just give him an extra 120mg dose?  I also read on here about green tea maybe helping?  At this point I am willing to try anything.  he is so swollen and I know he is feeling horrible. Plus, the swelling in legs and feet kept him (and I) up almost all night, so he is exhausted now also.
We live in a very rural area.  Keeping the dialysis clinic open on the weekends would just seem absurd to those people! How dare anyone need emergency treatment on a weekend??? 

Have to ask his doctor about increasing lasik - I would want to try it as that would be the easiest way to remove the excess fluid but it won't always work.


The unit is open only three times a week? NxStage might be a better fit than you think. Do you have access to home hemo training?

[alewis328]

We probably could access the training.  The way we understood it, someone has to be here at all times for that right?  To monitor and help and all that? We have virtually no support system. It is pretty much him and I against the big D here. I am and have been the only one working for the past year. He did finally start getting disability (thank God) but there is no way we can make it without my wages. I have a two hour per day commute and often work anywhere from 8 to 10 hours a day. This puts a serious restriction on things when it comes to someone constantly being here for home hemo.
Thank you for your reply.

[Bill Peckham]

Well this is a topic that has been brought up before. I've used hemodialysis, at home, by myself, since 2002. Since 1/08 I've used overnight dialysis. I live by myself. The way I see it is that whatever marginal safety issue is raised by self dialyzing, or being a lone dialyzor in Dr Agar's construct, is outweighed by the clinical benefit of dialyzing more frequently and longer and being personally in charge of this important part of your life.

Here are some IHD links:
  I want to do NxStage but I live alone - is this possible - is anyone else??
  Can anyone do NxStage?
  NxStage Training starts... (now with pictures)  Meinuk's awesome account of becoming a lone dialyzor
  How do I get on Nocturnal Dialysis  Dan's good advice on getting access to the least burdensome hemo modality

[MooseMom]

alewis, please read the links Bill provided.  Having to rely on inclinic dialysis when you live in a remote, rural area seems to be asking for trouble.  Home hemo requires dedication, but gosh, if he could dialyze at night, you'd be there anyway, right?  What seems to be apparent is that whatever treatment he is getting now isn't working.

[Desert Dancer]

We probably could access the training.  The way we understood it, someone has to be here at all times for that right?  To monitor and help and all that? We have virtually no support system. It is pretty much him and I against the big D here. I am and have been the only one working for the past year. He did finally start getting disability (thank God) but there is no way we can make it without my wages. I have a two hour per day commute and often work anywhere from 8 to 10 hours a day. This puts a serious restriction on things when it comes to someone constantly being here for home hemo.
Thank you for your reply.

I asked my clinic nurse the very same question; I thought it was a Medicare requirement or something. After much prodding, it turns out that they WILL let you dialyze alone. They take it on a case-by-case basis. It certainly can't hurt to ask.

I was never able to control my fluid until I started on nocturnal.

[lmunchkin]

alewis, if you did PD on him, you can learn NxStage!  It is a little envolved than PD, but have actually found it more suitable with NxStage. We control his care.  You make a visual and determine if more or less fluid needs removal.  Now I will tell you, it is not easy at first!  But thank goodness, I stuck with it, because he is feeling so much better and I have learned his symptoms very well.

I, too, work full time, but not as many hours as you though.  I work 7:00 to 3-3:30.  I get home, fix dinner then eat and hook him up to machine. It takes abouth 30 to 45 min. to set up. After hooking him and all pressures look good, I go do the dishes (15min tops), then check on him. Then I get quick bath and check on him. When all my me time has been taken care of I will climb in the bed and watch Tv together.  If not then I ll find something to do, read, go on Ihd, or whatever.

Now when we first got home, I was like OMG, will I ever get this.  I can honestly say, in a little over a month, It "Clicked".  And my nurse trainer was so patient with me and NxStage Tech support was even better!  Even though they are not in the room with you, they know of your problems just when you mention the type of Alarm or cannulating or anything to do with NxStage Dialysis.  They know there stuff, and will accomodate you with whatever you need.

I know that not all In-Centers are bad.  But Bad or Not, your bf,spouse or loved one is not going to get adequate cleansing of their blood.  Oh they maybe getting all his fluid off, but it's not just about the fluids, there are toxins building up in Bloodstream too.

I know about where my husbands dry weight is (I never knew before) by the signs he exhibits!  If I get carried away, I could "knock him out" LOL, but with him, his sign is BP & cramping with little headaches.  If he tells me he is cramping, then I knock his UF completely to "0" and run the rest of his time cleaning the toxins from his blood.  Just because he cramps or his BP gets a little low, does not excuse him from the rest that D. has to offer.
 
I think once you train for NxStage and work out the kinks (In your nerves espec.) it will "Click" with you too.  It just takes time and commitment, but it can be done and done very well for him!  If it is possible to love something, I do love it since we are at home doing NxStage. When He did PD for 5 years, it was like a process that I had to do, and I just followed the process! But with NxStage, yea its a process too, but you learn more about the "how and why's" things are done. PD was good modality, because we didnt have to go in-center!  It afforded us 5yrs, but now we've been doing nxstage for over a yr. I find it better to work with my schedule, plus I know he is getting good dialysis.  He is not just a number being attended to by a "non caring" person, he is at home!  That has a lot of implications on one's emotional well being.

Just try it if you can, Alewis!  Another thing, the training Nurse will not let you go until you are comfortable in doing it on your own. Even when I did go home, it was all Mind boggling, but I perservered, and am so glad that I did!!  You will need to take time off to learn this, so if considering, please make sure that you can take the time off.  It took me 3weeks at training center and nurse was home with us for a week!

Please give this a try!  If it don't work, then we will understand, at least you gave it a try!  Right?

Good Luck & God Bless,

lmunchkin     

P.S. I totally understand your time restraints, but if you do it at home, you can (after you feel comfortable) do things around the house while he is dialysing.  For about the first month or so, you might try winging yourself from the room a little at a time. It will become routine for you both!  The more you get use to doing it, you (both) will begin to relax and enjoy each others company. Believe me,it does get better.

[texasstyle]

About fluid overload, I can share some things that have happened to my husband from it. Keep in min though, he does not watch his restriction and they usually pull off about 13 lbs. every dialysis. It is scary and he doesn't get it. Fluid overload can (and everyone is different with different health issues of course), put yo in congestive heart failure. Too much fluid around the pericardium (heart sac) makes it difficult for the heart to pump adequetly. You "congest" and breathing becomes difficult . Most often a hosp  stay is required to rid the water from you as you know . My understanding is that there is something that can be done on a non dialysis day that just takes off the water. PUFF(?) Pure ultra filtrartion something..How are the diuretics doing? Possibly an increase Lasix may help. These are just a couple things that come to mind. Of, course the dr. will know what's best. Boy how I wish my husband was taking 5 lbs off. He averages about 13. He doesn't do the diet for the most part or restriction. Talk to the nutrionist! There may be ways to help keep the fluid down through that als.

[RichardMEL]

mmm that's a worry if you're restricting fluids - I'm guessing the usual liter or so a day (or as we say down here 500ml + urine output). If so it definitely does sound like a sodium profile may be being used (we NEVER used that down here) but it seems a likely candidate to check out.

I remember you suggested in an earlier post that it semed like at times they were taking too much fluid off (cramping, low BP etc) yet now he's overloaded? it seems like a real rollercoaster for you guys

I hope this can be sorted out very quickly!!

[texasstyle]

Richard, what is the sodium profile and maybe you can help me understanding even better just how the sodium effects things. I know it is like a sponge and retains water, but I think there's a lot more to the sodium than I am realizing or understand. Thanks!

[Bill Peckham]

I'll say how I think about it. The dialysate has sodium in it, and blood has sodium in it. During dialysis the two fluids try to have the same sodium level - that's what's meant by the gradient and solutes crossing the semipermeable membrane. Sodium is a type of solute; the gradient is the difference between the two sodium levels, for instance the dialysate sodium could be 138 while the blood sodium is 140.  The two fluids travel in opposite directions along the semipermeable membranes that make up what we think about as the artificial kidney. Because the sodium is higher in the blood (the difference is the gradient) when the two fluids pass by each other, through and around the straws in the artificial kidney, sodium (and other solutes) move from the fluid of higher concentration to the fluid with the lower concentration, in this example from the blood to the dialysate and then down the drain.

But the sodium in the dialysate can be adjusted. With "sodium modeling" the machine will change the sodium content of the dialysate, which then changes the sodium content of the blood, throughout the treatment. One common way is to start the treatment with a high sodium content, as high as 150 but more commonly ~145 and then finish the treatment with sodium lower. What can happen is that if the blood's sodium is 140 then instead of sodium going from the blood to the dialysate, sodium will go the other way. Sodium will cross from the dialysate to the blood. Improperly using sodium profiling ends up pumping sodium into the blood. It could be like eating a Denny's Moon over My Hammy each treatment.

Once that sodium is in your body you get thirsty. Bar tenders have know this for years - that's why you get peanuts and pretzels and pop corn for free - you'll drink more. When the body notices the sodium level of the blood increase it triggers the thirst signal and you are compelled to take in fluid. The body is trying to dilute the sodium in the blood. It forces you to take in fluid. That's why you hear about dialyzors sneaking Big Gulps on the way home from dialysis. It's why dialyzors drink out of the bathroom faucet when they're suppose to be washing their hands. The body is demanding they take in drink.

As far as sodium keeping fluid in the tissues this is the reason someone came up with sodium modeling, and why some docs think it is a good idea. In theory it will let you remove more fluid, more comfortably during dialysis. However, to do sodium modeling well is so hard that the advice the C-TEP came up with was basically you should not use sodium modeling. It's just being too widely misused. So without going any farther into the weeds to use it well you'd need to be sure of the predialysis blood sodium level and that is rarely known because it varies so much - you can't just go by monthly labs.

The other sodium related issue I've been banging on about lately is the data Dr Davenport presented at the ADC in February that showed incidental to a study when machines were independently checked as to the sodium they actually delivered vs. the sodium they said they were delivering, it was found that over 30% of the machines in the studied units were delivering the wrong sodium. Since then I've heard about another study where one of the incidental results was about the same thing. When people check, the machines are not calibrated to give the prescribed sodium. This must be a huge problem. Incenter dialyzors may be getting sodium sabotaged three out of ten treatments.

[texasstyle]

Thanks Bill so for much for helping me to understand that better. And for taking the time to be so exstentive.  Seems like just when you think you're learning a lot and can feel comfortable with some of the knowledge, you find how how complicated , and intriquete kidney disease and dialysis is. Thanks again for your time. Much appreciated. Carolyn

[Dannyboy]

@Bill.  Thanks for another enlightening mini-article about an aspect of Dialysis.   The stuff I don't know/haven't heard of is vast.  Thanks for the education.
----Dan

[texasstyle]

Dan, you'll earn a lot here just as I am. Hope you are feeling well today.

[Bill Peckham]

Here is the link to the C-TEP findings
https://www.cms.gov/CPMProject/Downloads/ESRD2010TechnicalExpertPanelReport.pdf


See page 133 (6.1; 6.2; 6.3) for Fluid weight Management C-TEP discussion of sodium modeling. Just a note about process. From here the C-TEP recommendations went to the National Quality Forum and they basically shit all over them, the result being that CMS couldn't use any of them as performance measures in their recently released Quality Incentive Program (but I'm not bitter).


Side note: I have never felt so above my pay grade as I did over the two days of the TEP meetings but someone should go to these things who actually uses dialysis, I had a good chance to be selected, so why not me?

[lmunchkin]

Thats great stuff, Bill. Let me ask you another question, that I have never understood. Back when hubby was in-center, his K was 5.4 I believe.  I know it was High, yet they continued to give him Potassium bath when they dialysised him. So I went to his neph and told her that he has had hi k levels and I wanted her to order it dropped or at least decreased.  These people could have killed him! Why do they continue in their incompetence?

TS, I liked your analogy of sponge & water, hey thats pretty good!

lmunchkin

 

[Dannyboy]

@Texasstyle:   RE: Learning on IHD.   Yep, I've learned tons of useful stuff here, there is so much available, and info coming from folks who've been there/done that is great too.

Feeling pretty good today, thank you.  Worked half a day today, first time since everything went south.
---Dan

[Bill Peckham]

Thats great stuff, Bill. Let me ask you another question, that I have never understood. Back when hubby was in-center, his K was 5.4 I believe.  I know it was High, yet they continued to give him Potassium bath when they dialysised him. So I went to his neph and told her that he has had hi k levels and I wanted her to order it dropped or at least decreased.  These people could have killed him! Why do they continue in their incompetence?

The thing with Potassium is that you don't want it too low, so usually incenter it is rare to see a zero 'K' bath (Dialysate with no potassium). A 2K bath is standard because you want the two levels (blood level and dialysate level) to meet somewhere in the middle, 5.4 is a bit high and 2 is too low, so if it all works right you finish treatment around 4 and then go up to five between treatments.
 
A good approach is to try to control potassium through diet and only as a last resort use an aggressive potassium bath level. One concern with zero K baths (the NxStage standard) is that a sudden drop in potassium could harm the cells that the blood comes in contact with. One thing with dialysis is looking at what can be done and deciding what should be done.

Aggressive potassium baths - 0K -  are often meant to make up for too short treatment times. Always better IMO to lengthen treatment times and use a 2K bath. A 3K bath is sometimes used and in my opinion this choice errors too far on the side of caution and then requires too strict dietary control of potassium to work.

All this is based on conventional incenter dialysis with conventional blood and dialysate speeds. And of course people are different. A two K bath is a sort of average that is appropriate for maybe 80% or 90% of the incenter census which means tens of thousands of people using something else appropriately.

NxStage is another matter but when I went from using NxStage in the evening, after work (3 to 4 hour runs) to using NxStage overnight, extended (7 to 8 hour runs) I switched from a 0K to 2K bath.

Think of that gradient - the difference between the solutes in the dialysate and the solutes in the blood - as being a way to increase how much the solute moves from one fluid to another. The bigger the difference, the faster the solutes will go to get from the crowded fluid to less crowded fluid. It is important to check that you have the right bath because of how quickly dialysis can remove stuff from your body. If you're suppose to be on a 2k3Ca (2 potassium, 3 calcium) and are mistakenly dialyzed with 0K or 0Ca you can be depleted in a hurry.

Any time there is a big difference - concentrations of potassium, calcium, sodium - between two fluids across a semipermeable membrane, for instance between the blood and the dialysate inside the artificial kidney, there is more movement from the crowded fluid to the less crowded fluid. More and faster solute movement, which sounds like it might be a good idea but I think that the body does better, over time, with gentler changes, over more time, always trying for a target range, not total elimination. All these things that end up being solutes in our blood, solutes that we try so hard to control - potassium, calcium, phosphorus, sodium - are needed in certain quantities. For us to feel like us, we need these things in our own specific balance - finding that balance is what we dialyzors should be trying to do.

[MooseMom]

Bill, after reading your posts about sodium modelling, I'm curious...is it EVER a good idea?  I understand that C-TEP says it's use is so unreliable that they recommend not using it at all, so if one of us is at our clinic and we overhear the words "sodium modelling", can we refuse?  How would we know if they were using sodium modelling?  And what is the rationale behind it's use in the first place?  You've said that "theoretically" it allows for more fluid removal, more comfortably for the patient, but is that just a big con?

I know I'm getting way ahead of myself on this, but I'm curious.

[lmunchkin]

Thanks Bill, that makes alot of sense when you put it that way.  But with NxStage, they revised our SAK-001 (which is one prescribed for Hubby) it had a label on the side giving the contents within the sak.  These new SAK-301 has contents listed but in a language Iam not familiar with.  Part of it is in either German or French and the other appears to be Spanish.  No english.  I have never asked if the contents are the same in both.  Should I ask if they are the same? This is what replaced his Sak-001, I just assumed the replacement was the same content too!  We know what assumptions mean, so now after reading your post, should I be concerned?

While on the subject, is there a way to do a little "extended" time without letting Neph know!  You know I really hate to bother them, if I could do it myself. (If you get my drift). I would like to run him about 5hrs for the first day of three, but feel as though I may need to increase dialysate amt for that time. Then run him 3-3:30 hours the other 2.  Since his labs have done very well and his ktv 4.75 to 5.0. should I just not change what we are doing and stick with what works?  I really want him to get best cleaning possible within the evening time when I come home from work.  I have been running him 3:10 to 3:20 for the 3 days.  2 days off, then another 3days.  Of course he loves it and I honestly do too.  I would rather increase the time, than to pick up another day, if it is possible!

He is very compliant in regards to his diet, so that is not much concern and fluid intake is n more than say 40oz at tops!
Whats your opinion?

lmunchkin   

[Bill Peckham]

Bill, after reading your posts about sodium modelling, I'm curious...is it EVER a good idea?  I understand that C-TEP says it's use is so unreliable that they recommend not using it at all, so if one of us is at our clinic and we overhear the words "sodium modelling", can we refuse?  How would we know if they were using sodium modelling?  And what is the rationale behind it's use in the first place?  You've said that "theoretically" it allows for more fluid removal, more comfortably for the patient, but is that just a big con?

I know I'm getting way ahead of myself on this, but I'm curious.

I'm glad you asked because I've been wanting to try and explain all this for a while because you have understand the whole ball of wax to understand the con of sodium modeling. Sorry I can't do it without some math. Apologies in advance.

It works because the body really doesn't like having salty blood. One thing the body can do is trigger the thirst response but that takes a little time. The immediate thing it can do is move fluid from the space between the cells to the blood compartment and sodium from blood compartment to the space between the cells. So it has the effect of increasing the 'transfer rate' of fluid between the compartments. And when fluid transfers it drags solutes with it. Getting more fluid and solutes into the blood compartment makes that stuff available to be removed by dialysis - sounds great so far.

That salt is now transferring into the intercellular space so now that space gets too salty, by the body's reckoning, so now the same thing happens. The body moves to fix this by moving fluid out of the cells themselves and sodium into the cells to make the fluid in the intercellular space less salty, and again with that fluid moving from the cells to the space between the cells, solutes are dragged along. So now that fluid and solutes are available to transfer into the blood compartment. That sounds really good. The whole problem with dialysis is that what you are really trying to do is not clean the blood - what you really need to do is clean the fluid inside your actual cells, all of them, from the tip of your nose and down to your toes - the solutes in the cells are far away from the artificial kidney and the drain. The truth is the kidney's job is not to clean the blood.

The vast majority of the fluid in the body is not in the circulatory system. Most of the fluid is inside the cells. For every 1 liter of fluid in the circulatory system there is about 4 liters of fluid in the cells. And there is an additional 2 liters of fluid in the space between the cells (there are other fluid spaces (see Agar's post on eating for the one relating to digestion, the liver and bone have blood that isn't part of this main process I'm describing) those are the main ones. If your job entailed 7 things, and one of them, say driving a truck or a shop van, was one of those things: Would you say your job was driving the van? or is your job the 6 things you do after you get there? Of course it's the six jobs. The kidney's job, and dialysis's job, is to clean the body's fluid. Add their main job is to keep the fluid in the cells clean.

And part of that cleaning is keeping the fluid amount the same between all the spaces. Wait, I hear you saying. How can they all be the same? You just said their relative sizes are 4 to 2 to 1? Well, the body has in mind your dry weight, in the dialysis sense, your body know how much fluid it should have in each space, it's ideal level of hydration (BTW the proper term isn't dry weight, it should be ideal level of hydration) No one, and I mean no one else in the world, knows this number, not even your conscious mind. But somehow your body decides what it is and that is where it is kept when you have healthy kidneys. When you don't pee you keep the fluid in and so you exceed this ideal number. You're over hydrated. All that fluid doesn't go into any one or two spaces. If you are 5% over your ideal hydration then every fluid space has to accommodate 5% more fluid.

To try to tie this together imagine a guy whose ideal hydration is 70 liters of fluid, and with his build/body that puts his dry weight at 115kg, we'll cal him Dialysta.

>>--<<

Dialysta has been sneaking fluid, he feels guilty about it but he can't help it. He dreams of pouring ice cold water down his throat. He use to fly in his sleep, now his dreams are all some version of him standing somewhere pouring bottomless pitchers of water down his parched throat. Dialysta comes in on Monday for dialysis, he had an unquenchable thirst all weekend, he did his best, he really tried, he weighs in at 122. The nurse explains to him, again, that this behavior is damaging his body. The dietitian comes over and gives him a sample of quench gum, again. They all tell him, correctly and with compassion, of their concern. Dialysta, they say, you're stretching the circulatory system. It's like a balloon ... True but an a more accurate way to say what's going on is that that every fluid compartment is 10% over it's ideal volume - that 7KG is all fluid, and it' all over his body, distributed evenly. This means instead of having 40 liters of fluid, the cells have 44 liters. The space between the cells has 22 instead of 20, and the blood stream has 11 liters. Everything is 10% over ideal.

To remove this fluid, Dialysta can't just take it all off in a hour because he'd be way below how much fluid his blood compartment needs to function. I"m not sure where the body will cramp/crash but I think it is at about 90 to 95% of the body's ideal blood compartment volume. For Dialysta we're going say he crashes when his blood compartment volume drops below 92% of its ideal, so for Dialysta it's 9.2 liters. That's Dialysta's dialysis speed limit if he gets below 9.2 liters of fluid in his blood compartment, Dialysta crashes. Plus the body replenishes the blood compartment as dialysis is happening, the transfer rate.  Dialysta's natural transfer rate from the intercellular space to the blood compartment is about .5 liters an hour.

So consider if Dialysta had a run without sodium modeling: after 1 hour at an ultra filtration rate of 1.2 liter/hour his fluid compartment would have 10.6L (11-1.2+.5 have to add in the saline prime at hookup +300ml). At that UFR he can loose .7 an hour net from the blood compartment so after hour 2 the blood compartment is at 99% of ideal but Dialysta has only taken off 2.4 KG. Now hour 3 passes and Dialysta's fluid compartment is at 92% - and he still has half his excess fluid to remove. Cramp. The UFR is turned off or way down. The last hour is hell but the transfer rate eventually catches up, or Dialysta is given saline (aka salty fluid). You'd be looking at leaving 3 kilos over.

But wait let's use sodium modeling. Dialysta starts with a high sodium bath. The transfer rate increases. Here I am not sure what the numbers are but as the sodium increases Dialysta's transfer rate increases. With a higher transfer rate Dialysta could comfortably dialyze at a 1.2 UFR. He might even be able to get to a 1.6 or 1.8 UFR to get all the fluid off without cramping. That would imply a transfer rate of 1.1 or 1.3, respectively but I think with enough sodium the body can make that happen. The body is that desperate to dilute the overly salty fluid.

If I stopped here I reckon I've made a pretty strong case for sodium modeling right? I mean sign me up! Instead of spending 8 hours a night 5 days a week to get those nose and toe cells clean and take off 17 liters of fluid each week Dialysta should just do sodium modeling. But, there is always a but, there just is.

Now Dialysta has a bunch of sodium in all the fluid in his body. This whole time Dialysta's body has desperately wanted to even things out, to get the sodium level lower until it can get it back to normal (by getting him to drink fluid). So if the sodium modeling was left on the whole time Dialysta could have gotten thousands of mg of excess sodium. That happens a lot. Or it is turned down too little as his treatment goes along. The longer you leave the sodium level high the longer it will take to get it down. All the staff know is, they're suppose to get you to 'dry weight'. The staff believe that they will be helping you if they can get the fluid off and they can not get the fluid off through traditional means. But they've come to find out they can do it, they can crank up your UFR, if they use this magic process. All they have to do is go to one of the screens on the machine display and activate sodium modeling. It's the George Jetson solution - they can do their job by pressing a button. BUT then next time when Dialysta comes in, he'll be 6 liters over because he's been so inexplicably thirsty. He assumes everyone using dialysis gets this thirsty but only he is so weak that he gives into it, it feels like this is all his fault. He doesn't have the will to control his fluid intake. And the cycle will be repeated.

>>--<<

That's a mess. But it's the dynamic at work all across the country. I think to use it right you have to be, either former FMC CMO Dr Lazarus who I think figured it all out in the first place, or one of the fellows who listened to him when he was teaching them how to use it. He would have explained that the problem with getting that sodium back out once it's migrated to the cells - in other words after a couple hours - is it takes a long time to get out. It's going from a larger spaces to smaller spaces, rather than from small spaces to large. The dynamics are reversed, it goes much slower out then it did in because once you lower the dialysate sodium and thus the blood sodium the transfer rate declines. The body thinks that the blood isn't salty enough so it slows the transfer of fluid from the intercellular space to the blood compartment. The body really wants its sodium level where it wants its sodium level.

Two hours one way two hours the other doesn't work. It'd have to be more like 1.5 hours one way 3 hours the other, but now I'm over the 4hr allotted time. This all not even to mention there has been no long term studies on the effect of routine sodium dosing in terms of CVD or brain function or anything else including withdrawal from dialysis because Dialysta is going through hell! Physical and mental hell. How long is Dialysta suppose to take this? When I read articles like the caregiver piece in the NYT recently, this is what I think: Sodium. 

[monrein]

Great explanation Bill!  I only did sodium profiling once and it was perfectly awful to be so thirsty afterwards.  It all points to the importance of doing what can be so difficult...controlling intake of fluid and sodium in the first place...dialysis is tough enough without the added heroics.