This question is medical in nature. I have asked several nurses and have not gotten a good answer yet. Unfortunately, I have gotten too many defective dialyzers and both the lines and the dialyzers do not clear out well at rinseback. My question is, what does repeated blood loss do to the body? I understand that hgb/hct will be affected and higher medication dosing will be required to keep the blood up. But what else, specifically, does repeated blood loss with poorly performing dialyzers do to the body? This is a concern, because with daily dialysis and poor dialyzers, the blood loss is 6x instead of 3x.
You’d need to know how much blood is being loss. At any one time about a cup of blood is in the dialyzer and blood circuit, so that would be the maximum loss. What you’re seeing remain typically in the kidney and if the lines are pink would be a tiny fraction of that. I’d say less than one vial drawn for labs.
Individual strands of the dialyzer clotting doesn’t help you but I don’t think there is a significant clinical impact. A larger question is the impact of mechanical blood pumps on blood cells. One imagines that physical pumps damage a certain number of cells during a conventional treatment, where as the pumping mechanism in the NxStage System One would damage fewer cells. There isn’t any actual data that I’ve seen on blood pump hemolysis so this is speculation.
[QUOTE=Bill Peckham;15333]You’d need to know how much blood is being loss. At any one time about a cup of blood is in the dialyzer and blood circuit, so that would be the maximum loss. What you’re seeing remain typically in the kidney and if the lines are pink would be a tiny fraction of that. I’d say less than one vial drawn for labs.
Individual strands of the dialyzer clotting doesn’t help you but I don’t think there is a significant clinical impact. A larger question is the impact of mechanical blood pumps on blood cells. One imagines that physical pumps damage a certain number of cells during a conventional treatment, where as the pumping mechanism in the NxStage System One would damage fewer cells. There isn’t any actual data that I’ve seen on blood pump hemolysis so this is speculation.[/QUOTE]
I’m speaking of a worse case scenario when let’s says, 75% of one’s 24 monthly dialyzers are not clearing well and the lines and dialyzer are full of blood. Or, put another way, let’s say one loses maybe 1/2 c.-1 c. of blood 18 out of 24 txs.- what are the clinical effects? Is there nothing to worry about, because losing that much blood is not detrimental to the body? Or should that be a serious concern? I know, as I said previously, that blood loss effects hgb/hct requiring 2-3 more times the EPO, iron and heparin. That’s a cost to Medicare. One becomes anemic. So, what I want to know is , what other immediate or long term effects does continual blood loss, as I’ve described, have on the body, if any?
Are you saying losing the entire circuit?
Or being able to rinseback and just fibers in the dialyzer not clearing well?
Thats a big difference.
In a high flux dialyzer (F-80B) the blood comparment can hold up to 130cc of blood.
Now, when you think that there are hundreds of fibers in that dialyzer, thats a small fraction of blood in each. Say each has 1000 fibers, each would hold .013cc of blood.
If 100 clot off, thats 1.3cc of blood lost. At 26 treatments (double what incenter is allowed monthly) that is 33.8cc a month lost. This is a relatively small amount (as was stated earlier, like a vial of blood taken for labs).
If you loose the entire system, that is about 200cc at a time. That is reportable to the FDA. If it happens the patient should make sure they notify their provider so that it is documented. That is a much larger impact and becomes an issue of why it occurred.
[QUOTE=Unregistered;15341]Are you saying losing the entire circuit?
Or being able to rinseback and just fibers in the dialyzer not clearing well?
Thats a big difference.
In a high flux dialyzer (F-80B) the blood comparment can hold up to 130cc of blood.
Now, when you think that there are hundreds of fibers in that dialyzer, thats a small fraction of blood in each. Say each has 1000 fibers, each would hold .013cc of blood.
If 100 clot off, thats 1.3cc of blood lost. At 26 treatments (double what incenter is allowed monthly) that is 33.8cc a month lost. This is a relatively small amount (as was stated earlier, like a vial of blood taken for labs).
If you loose the entire system, that is about 200cc at a time. That is reportable to the FDA. If it happens the patient should make sure they notify their provider so that it is documented. That is a much larger impact and becomes an issue of why it occurred.[/QUOTE]
What I observe is, the lines do not clear, the dialyzer has thick red lines rather then fine pin-striping, the end caps are blood red and blood leaks out the art line all the way into the cartridge. This is a worse case scenario, but I get more like this than I do normal returning cartridges. I also get the situation where the lines clear, but the dialyzer does not. I have diligently reported the problem to my clinic and the co. I have no way to measure how much blood is lost- can only give this description. But my question remains, obviously the conditions I am seeing point to blood loss, and I’d like to know if anyone out there in Dialysis Land can tell me, what are the short and long-term consequences of the amount of blood loss I am seeing, if any? Or to put it another way, how much blood can the human body lose per dialysis tx, in this case 6x/week, without cause for concern?
It sounds like it would help if you could take digital pictures of your dialyzer from the side and ends and post the pictures here so people could see whether the way your dialyzer looks post-dialysis is different from what they observe. You might also want to add how much heparin you use during dialysis and when you give it.
Have you taken a used dialyzer to the dialysis clinic to show to the home training nurse? If so, what does he/she say about how it looks? What has your nurse suggested that you do to get more of your blood returned at the end of treatment?
What is the effect of the blood loss that you’re experiencing on your hemoglobin or hematocrit? Are you having your blood drawn monthly and is your H&H measured at that time? Is your Hb - 11-12 and/or Hct 33-36? Is your ferritin level 100-800 mcg/L? Is your TSAT 20-50%?
Most people on frequent dialysis have reported a reduced need for EPO. However, if blood loss during dialysis is dropping your your levels lower than this and your EPO dose isn’t compensating, you could have the same complications as for untreated anemia, which can include such symptoms as shortness of breath, fatigue, rapid heartbeat, chest pain, concentration & memory problems to serious problems related to the heart like left ventricular hypertrophy and even heart attack.
As a social worker, I also wonder how is this blood loss during dialysis affecting your ability to perform daily activities? Do you have problems walking, climbing stairs, exercising, doing activities around your house, doing activities with your family, working or volunteering full or part-time, etc.? If you were to say how serious your symptoms are on a 10 point scale from zero to ten, where would you put them routinely and after you have a dialyzer that is as you describe? Keeping track of this over time using a scale may help your doctor and home training nurse evaluate the effect on you more easily.
[QUOTE=Beth Witten MSW ACSW;15348]It sounds like it would help if you could take digital pictures of your dialyzer from the side and ends and post the pictures here so people could see whether the way your dialyzer looks post-dialysis is different from what they observe. You might also want to add how much heparin you use during dialysis and when you give it.
Have you taken a used dialyzer to the dialysis clinic to show to the home training nurse? If so, what does he/she say about how it looks? What has your nurse suggested that you do to get more of your blood returned at the end of treatment?
What is the effect of the blood loss that you’re experiencing on your hemoglobin or hematocrit? Are you having your blood drawn monthly and is your H&H measured at that time? Is your Hb - 11-12 and/or Hct 33-36? Is your ferritin level 100-800 mcg/L? Is your TSAT 20-50%?
Most people on frequent dialysis have reported a reduced need for EPO. However, if blood loss during dialysis is dropping your your levels lower than this and your EPO dose isn’t compensating, you could have the same complications as for untreated anemia, which can include such symptoms as shortness of breath, fatigue, rapid heartbeat, chest pain, concentration & memory problems to serious problems related to the heart like left ventricular hypertrophy and even heart attack.
As a social worker, I also wonder how is this blood loss during dialysis affecting your ability to perform daily activities? Do you have problems walking, climbing stairs, exercising, doing activities around your house, doing activities with your family, working or volunteering full or part-time, etc.? If you were to say how serious your symptoms are on a 10 point scale from zero to ten, where would you put them routinely and after you have a dialyzer that is as you describe? Keeping track of this over time using a scale may help your doctor and home training nurse evaluate the effect on you more easily.[/QUOTE]
Hi Beth,
I have already taken all the measures you propose. My hgb/hct are on the low side of normal as of my last monthly labs. My #'s have been in range the entire period ( many months) of the faulty dialyzers. My iron trends did show a significant drop, but I tripled up on oral iron and went back in range again. But the key thing is, I have had to use 2-3 times the heparin, EPO and iron that I used when I did 3x dialysis in-center to stay in range. So the increased dosage of drugs does compensate for the blood loss, but the question is, will there be any short or long term effects from the blood loss and my higher intake of drugs?
Whereas I do not feel unwell, my bp has dropped into a lower range during this period. My team and everyone I’ve shown the cartridges to, all acknowledge the rinsebacks are poor. But no one has expressed that they see it as a serious problem since my #'s are in range. Some patients have done double rinsebacks during this period to compensate. I have tried it, but too much saline comes back and the dialyzer/lines still do not clear well. There really is nothing that can be done until the co. finds the fix for the dialyzers. So, my main question is, yes I am in range, but should so much blood loss beyond what a good performing dialyzer would allow, and the fact that I have had to take increased amounts of drugs be a concern?
Getting heparin throughout the treatment has made the 171 cartridges I use for extended much clearer and no end-cap clot/little streaking. (171s appear to be identical differing only in not having an arterial alarm and adding a heparin line.
You could see if your unit would provide you with a stand alone heparin pump and order up some 171s. So you could give your current dose spread across the first part of the treatment. You could see if spreading the heparin out would help by splitting your dose and giving yourself a bolus after an hour.
Jane;
Think we were having the same problem with the rinse back… The lines rinsed back clear but the dializer was still red…had to increase the Heparin to try to see if we could get the dializer to rinse clear… That is until we got the new batch of cartridges (CAR-171’s) with the date code 7117702.(our clinic told us not to use these anymore LEAK problem with them)… now using 7117709’s these new cartridges rinse back clean… no blood left in the dializer… Even reduced the amount of Heparin and the dializer still rinse back clear…
You might have them check your Platelets count… My partners platelets count have been steadily decreasing from Dec 2006 to Nov 2007… It was such a concern that her Neph ordered a Heparin Induced Thronbocytopenia blood test to see if the increase in Herarin is causing this decline in platelets count… What is strange is all of this is happening since she switched from the Fresenius to the NxStage… She is also back on High Blood Pressure Meds, and now her Potassium is on the low side so she has to take postassuim pills. She has started to use a 2K bath (SAK004) for the pureflow. Have been on it for a week. We draw blood tonight so will see what is going on with her blood work in a few days…
HemoHelper
[QUOTE=Bill Peckham;15351]Getting heparin throughout the treatment has made the 171 cartridges I use for extended much clearer and no end-cap clot/little streaking. (171s appear to be identical differing only in not having an arterial alarm and adding a heparin line.
You could see if your unit would provide you with a stand alone heparin pump and order up some 171s. So you could give your current dose spread across the first part of the treatment. You could see if spreading the heparin out would help by splitting your dose and giving yourself a bolus after an hour.[/QUOTE]
This would of been a possible solution. The thing is, I’ve been getting the defective cartridges for months and the problem is “almost fixed now”, I’m told. Should I find it is not, I will certainly hold onto this advice…thanks!
[QUOTE=HemoHelper;15352]Jane;
Think we were having the same problem with the rinse back… The lines rinsed back clear but the dializer was still red…had to increase the Heparin to try to see if we could get the dializer to rinse clear… That is until we got the new batch of cartridges (CAR-171’s) with the date code 7117702.(our clinic told us not to use these anymore LEAK problem with them)… now using 7117709’s these new cartridges rinse back clean… no blood left in the dializer… Even reduced the amount of Heparin and the dializer still rinse back clear…
You might have them check your Platelets count… My partners platelets count have been steadily decreasing from Dec 2006 to Nov 2007… It was such a concern that her Neph ordered a Heparin Induced Thronbocytopenia blood test to see if the increase in Herarin is causing this decline in platelets count… What is strange is all of this is happening since she switched from the Fresenius to the NxStage… She is also back on High Blood Pressure Meds, and now her Potassium is on the low side so she has to take postassuim pills. She has started to use a 2K bath (SAK004) for the pureflow. Have been on it for a week. We draw blood tonight so will see what is going on with her blood work in a few days…
HemoHelper[/QUOTE]
Yes, it has been the same situation for us doing SDD although I have had many txs when neither the dialyzer or the lines rinsed back. I got one box of good performing cartridges, recently, but after that got cartridges that were defective again. So the faulty ones are still being distributed, but my understanding is it won’t be for long.
I have kept my eye on my platelets, but not a problem in my case. However, it has concerned me greatly that I have had to almost triple my heparin dose for many months now. Also, I do not have a problem with low K or high bp, but I have had a change in that my bp now runs 10 points lower. Will be interested to hear your partner’s blood results. Hope they are improved.
But for anyone who has read this thread, one can readily see that sometimes it is difficult to get a simple answer to a question. My need is still to know- what has the months of blood loss and increased meds done to my health, if anything?
I gather that there were problems reported in the past with certain NxStage dialyzers. I assume that NxStage knows the lot numbers of those dialyzers and you could check to see if the lot numbers on the dialyzers you have that are having problems fall into the ones that NxStage knows about.
If you’re not already doing this, a nurse I know suggested that you wait three minutes after giving your heparin to hook up so your body is completely heparinized before the blood hits the dialyzer.
I’ve been told repeatedly that making sure that problems are reported to NxStage is the only way to get them resolved. Make sure that your home training nurse in talking with the NxStage clinical educator about the problems you’re experiencing. This could lead NxStage to ask its medical review board to review those concerns and evaluate what could be the cause of them.
HIT test negative… can continue to use Heparin to stop blood clotting… also using the 2K potassium pureflow SAKS have and potassium pills have made my partners potassium level back up to 4.3…
HemoHelper
[QUOTE=HemoHelper;15352]Jane;
Think we were having the same problem with the rinse back… The lines rinsed back clear but the dializer was still red…had to increase the Heparin to try to see if we could get the dializer to rinse clear… That is until we got the new batch of cartridges (CAR-171’s) with the date code 7117702.(our clinic told us not to use these anymore LEAK problem with them)… now using 7117709’s these new cartridges rinse back clean… no blood left in the dializer… Even reduced the amount of Heparin and the dializer still rinse back clear…
You might have them check your Platelets count… My partners platelets count have been steadily decreasing from Dec 2006 to Nov 2007… It was such a concern that her Neph ordered a Heparin Induced Thronbocytopenia blood test to see if the increase in Herarin is causing this decline in platelets count… What is strange is all of this is happening since she switched from the Fresenius to the NxStage… She is also back on High Blood Pressure Meds, and now her Potassium is on the low side so she has to take postassuim pills. She has started to use a 2K bath (SAK004) for the pureflow. Have been on it for a week. We draw blood tonight so will see what is going on with her blood work in a few days…
HemoHelper[/QUOTE]
My daughter and I were hoping to start home hemo this Friday but Mon. and Weds. of this week her machine clotted off prior to the complete treatment. Its frightening to see a pint of her blood be thrown away when shes still anemic let alone two! Her albumin level is low preventing a transplant and we surely dont want her to have to receive a transfusion since italso has issues regarding transplant . Has anyone had this happen to them more than once in 3 days and if so how often and what was your solution? The training nurse tried to get at least some returned by rinse back but the nx stage refused and of course then you have to fear the clots being returned as well !!