Home Dialysis Central

Page 1 of 2 12 LastLast
Results 1 to 10 of 12
  1. #1
    Join Date
    10-25-15
    Posts
    13

    Unhappy Blood pressure fluctuations during hemodialysis

    I have been crying everyday worrying about my mom's hemodialysis. I came across this site and hoping Dr Agar will answer my questions.

    My mom has been on hemodialysis for the past 20 months or so. Since the very first day of dialysis, her blood pressures are hard to manage throughout the treatment. She doesn't take BP medications before dialyzing, and goes to the clinic with a BP of 180/90. Once they start dialyzing, her BP slowly drops down to 90/60 in about 1-1.5 hours. Then, if she feels really bad, they give her saline and ask her to lay down, and stop pulling fluids for about 20 minutes or so until her BP rises again. Her BP will gradually rise to about 160/60, upon which they will start pulling fluids again. Again, after 20 mins, the BP drops to 90/60, and the same process continues throughout the treatment. She goes to the center 3 times a week for 4 hours/day where they try to pull about 2.8-3.5L in 4 hours. We told them multiple times not to pull at a faster rate, but they don't listen to us saying that they have to achieve her dry weight of 60 kg. My questions are:
    1) The BP flucations are not common among other people I see in the clinic. Why is my mom's BP fluctuating? What can be done to stabilize the BP?
    2) My mom feels good only when her BP stays around 140-160 systolic. At other times, she feels bad. What should be the target BP range for dialysis patients during dialysis and non-dialysis days?
    3) A few days ago, her BP hit 220/110 an hour after dialysis where she had a severe chest pain and went to the ER. They checked her heart and said everything is normal. When I asked for the cause of the high BP, they weren't sure what caused it. But, my mom told me that they pulled fluids really fast on that day by setting the UF rate to 1100 which caused her heart to beat really fast. Could this be the cause of the high blood pressure right after dialysis on that day?
    4) My mom takes 3 different blood pressure medications (a total of 5 tablets/day) to manage BP's. Is she supposed to stay on those BP medications throughout her life? What should she do to bring her BP under control without taking any BP medications?

    Thanks for your time Dr.

  2. #2
    Join Date
    11-17-09
    Location
    Geelong, Victoria, Australia
    Posts
    467

    Default Re: Blood pressure fluctuations during hemodialysis

    Dear John1234

    I have dealt with exactly this issue, many times, and yes ... it makes me weep, too, that so many patients are put through the misguided process of draconian fluid removal - again and again.

    You will find a seizes of 4 blogs on this issue ... the first two being a description of the problem, the last two focussing on the solution.

    They are at the HDC weekly blog site that I do with Dori Schatell from the Medical Education Institute in Wisconsin. The site is called KidneyViews - the main blog 'guidance page' of which can be found at ... http://www.homedialysis.org/news-and-research/blog ...


    The volume blogs can be found, in reading order, at:

    http://www.homedialysis.org/news-and...ll-forget-urea

    http://www.homedialysis.org/news-and...terfall-part-2

    http://www.homedialysis.org/news-and...s-duration-kpi

    http://www.homedialysis.org/news-and...ing-volume-101


    And if you haven't had enough by then, there are two others ...

    http://www.homedialysis.org/news-and...e-water-dragon

    http://www.homedialysis.org/news-and...-there-is-hope


    Most of these are written in (mostly) lay-terminology. They tend to be repetitive around the same theme - mainly to try to drive the simple concepts home.

    You should read them in the order I have listed them.

    This is a weekly blog - so, sooner or later, I am sure that I will come back to the same theme. With that in mind, I have been asked to give this message twice at the Annual Dialysis Conference in Seattle in February - once as the conference opener, and once again during the course of this 3.5 day annual event.

    I hope these URL's help though you may need to copy them into your browser individually ...
    Last edited by John Agar; October 29, 2015 at 05:11 PM.

  3. #3
    Join Date
    10-25-15
    Posts
    13

    Default Re: Blood pressure fluctuations during hemodialysis

    I have read a few of your blogs and I will wait to read these as well. Also, if you could answer my other questions as well in my original post unless the readings cover those, I would really appreciate it. Thanks for everything you do to help others.

  4. #4
    Join Date
    11-17-09
    Location
    Geelong, Victoria, Australia
    Posts
    467

    Default Re: Blood pressure fluctuations during hemodialysis

    I hope these give you some guidance.

    But, there ARE other parts to your original question ...

    The multiple keys to breaking her horrible cycle of rapid fluid removal ... followed by an ill-advised 'rescue therapy' of saline administration to resuscitate her from the crashing BP that has resulted (and remember, it is salt and water that we are trying to remove!) ... followed by more rapid fluid removal ... followed by yet another crash ... and on, and on it goes ... iare:

    (a) SLOW DOWN THE DIALYSIS! ... But, to be fair, you haven't given me any information about your mother's weight, her underlying renal disease, and a raft of other information I would build into a specific solution for her (as an individual dialysis patient) ... and to be honest, even if you did, from 12000 miles away, I still couldn't do that - and it would be wrong of me to try to do so ... but, by general principles, your mum needs longer, slower, gentler, more physiologic dialysis than it appears to me is happening right now.

    The blogs I have sent you will, I hope, give you a glimmer of why this is so.

    (b) Turn down the temperature of her dialysate. It amazes me that some US dialysis units (and this is hearsay, so I DO need to be cautious that I don't tar all with the same brush) still seem to run dialysate temperature at 37 degrees(!) ... or close to that. The dialysate temperature should be run at least at 0.5 degrees less than the pre-dialysis tympanic membrane temperature (assuming no fever or infection). We routinely run our patients at 35.5. Lowering the dialysate temperature makes a huge difference ... just think of what the cardiac surgeons do to minimise tissue damage during heart-lung surgery ... they put the patient (and their tissues into a kind-of suspended animation by turning down the temperature of the body to something like 18-20 degrees. Lowering the dialysate temperature stabilises the therapy and reduces tissue injury!

    (c) ... and this addresses some of the questions embodied in your question (3) above ... the vast majority of our patients take NO BP PILLS at all. Charles Chazot and his mentor Bernard Charra have shown in Tassin, France, for at least 40 years now that a vanishingly few dialysis patients need blood pressure pills at all - yet my understanding is that a majority of US patients are one anti-hypertensive medication (and many on multiple drug therapy).

    Now ... this is a complex point to make here, and it is hard to do it justice in a lay explanation, but, try to follow along here ... almost to a man, woman and child, the US dialysis patient population is chronically ... and horribly ... volume overloaded - even when the so-called "dry weight" = RUBBISH, as it's nowhere near dry weight, is reached at the end of dialysis. At the end of dialysis, most US patients remain overloaded to hell!

    But, as I will hear dialysis professionals screaming ... their BP is in their boots! How CAN they be wet? They are hypotensive!

    Wrong. They are intravascularly dry as a chip - yes ... their intravascular volume has been cruelly assaulted ... cruelly. But theor tissue and cellular volumes are still bulging with fluid.

    Read the blogs! It takes TIME to waterfall!

    Dialysis plunders the blood volume, not the interstitial volume (that big amorphous space that lies OUTSIDE the blood vessels but also OUTSIDE the cells in the spaces between cells). Dialysis certainly doesnt reach the fluid volumes within the cells (the intracellular fluid) which can only begin to reduce once the interstitial volume has well and truly begun to reduce.

    So ... OF COURSE the patient crashes. The blood volume has been cruelly and rapidly reduced and so the BP cannot do anything BUT fall - or crash. Meantime, the interstitium and the cells are still awash.

    It takes TIME, and SLOWNESS, and GENTLENESS!

    Sorry for the capitals (that is meant to represent shouting on the Internet) but I feel bound to shout until someone hears and understands this stuff. And, it ain't rocket science!

    To make matters worse, your mum (and so many others) are weighed down with BP pills. These simply complicate any attempt to remove fluid. As soon as dialysis ends, and the 'equilibration process' begins to equalise out the remaining hugely expanded volume of fluid left in her two largest 'compartments' ... the intracellular and the interstitial compartments ... with her (in contrast) tiny intravascular compartment ... the intravascular compartment fills back up and her BP rockets back up!

    Solutions.

    1. DROP her dialysate temperature to proper cool dialysis (35.5)

    2. LENGTHEN her dialysis sessions such that her mean predicted UFR is around 7.5 ml/kg/hr (and in this case - at least till she's dried down properly - I'd be shooting for a conservative figure laike 7.5 rather than the upper range of safe = 10) ... that could be the later aim once she is volume neutral. And, if she has to sit in the chair an extra 2 hours to allow that ... so be it ... she needs to!

    3. REDUCE her target weight by 0.25 kg every second treatment

    4. SEQUENTIALLY withdraw her BP pills, starting with the vasodilators and calcium channel blockers, leaving the ACEIs or ARBs and beta blockers till last. A small ongoing dose of something like carvedilol may be wise to sustain but, over a period of 2-3 months ... AND THAT'S HOW LONG IT MIGHT (AND LIKELY SHOULD) TAKE ... she should manage to get several kilos of extra 'hidden' fluid off, run stable runs, and feel human again ... without an anti-hypertensive pill burden.

    Tassin does it. We do it. So should your mum's team.

    Issue: in the dialysis-for-profit system of the US, squeezing the extra 1, 1.5, 2, or 2+ hours/session out that are needed to succeed are problematic ... but then the whole US dialysis system (or most of it) is too. In Australia, new facility-based haemodialysis patients quite commonly start with a 5 hr regimen. That's 5 x 60 = 300 minutes/session. In the US, the mean dialysis time is something like 211 minutes (from DOPPS data). That is a whopping difference of 89 minutes per session. And, the mean dialysis time here is up around the 280 minute range. And our dialysis mortality is <1/2.

    There's a message in that.

  5. #5
    Join Date
    10-25-15
    Posts
    13

    Default Re: Blood pressure fluctuations during hemodialysis

    Thanks for the detailed explanation Dr. Your response makes really good sense. I will go over the blogs and ask questions if I don't understand something. Again, thanks for your time.

  6. #6
    Join Date
    10-30-15
    Posts
    2

    Default Re: Blood pressure fluctuations during hemodialysis

    Quote Originally Posted by John Agar View Post
    Dear John1234

    I have dealt with exactly this issue, many times, and yes ... it makes me weep, too, that so many patients are put through the misguided process of draconian fluid removal - again and again.

    You will find a seizes of 4 blogs on this issue ... the first two being a description of the problem, the last two focussing on the solution.

    They are at the HDC weekly blog site that I do with Dori Schatell from the Medical Education Institute in Wisconsin. The site is called KidneyViews - the main blog 'guidance page' of which can be found at ... http://www.homedialysis.org/news-and-research/blog ...


    The volume blogs can be found, in reading order, at:

    http://www.homedialysis.org/news-and...ll-forget-urea

    http://www.homedialysis.org/news-and...terfall-part-2

    http://www.homedialysis.org/news-and...s-duration-kpi

    http://www.homedialysis.org/news-and...ing-volume-101


    And if you haven't had enough by then, there are two others ...

    http://www.homedialysis.org/news-and...e-water-dragon

    http://www.homedialysis.org/news-and...-there-is-hope


    Most of these are written in (mostly) lay-terminology. They tend to be repetitive around the same theme - mainly to try to drive the simple concepts home.

    You should read casesam.co.uk them in the order I have listed them.

    This is a weekly blog - so, sooner or later, I am sure that I will come back to the same theme. With that in mind, I have been asked to give this message twice at the Annual Dialysis Conference in Seattle in February - once as the conference opener, and once again during the course of this 3.5 day annual event.

    I hope these URL's help though you may need to copy them into your browser individually ...
    They're all good place. Thanks. These URLs ourcase.co.uk must really be benefit to you.
    Last edited by IUafasdhj; November 1, 2015 at 07:27 PM.

  7. #7
    Join Date
    10-25-15
    Posts
    13

    Default Re: Blood pressure fluctuations during hemodialysis

    Hi Dr Agar, I have a question. So, my mom's ideal weight would be 60 which makes the plasma refill rate to be 300 ml/hr according to your article. In this case, what do you recommend for the UFR to be set for a 4 hour dialysis session so that we can avoid plasma volume contraction? Thanks.

  8. #8
    Join Date
    11-17-09
    Location
    Geelong, Victoria, Australia
    Posts
    467

    Default Re: Blood pressure fluctuations during hemodialysis

    As per my HDC blogs, the notional plasma refill rate, while a variable number and dependant on many things, is - for the 'average' person - thought to be about 5 ml/kg/hr (which for a 60 kg woman equates 300 ml/hr). As the risk range for heart problems like myocardial stun seem to rapidly ramp up beyond a removal rate of 10 ml/kg/hr (which for a 60 kg woman equates 600 ml/hr), this would be about as fast a removal rate of fluid that is 'safe' for her. Over a 4 hour dialysis, this equates to the removal of 600 x 4 = 2400 ml = 2.4 litres). So, using that logic, and in round figures and without knowing your mother's specific circumstances, her biochemistry etc. ... to therefore ensure that her UF rate stays within a 'stun-safe' range, it would seem that her maximal weight gain from one dialysis treatment to the next should be no more than about 2.4 kg.

    There are only two levers to pull, here, to ensure UF-safe dialysis. Keep her inter-dialytic fluid gains to less than 2.4 (say 2.5) kg ... or to increase her treatment time. As limiting fluid intake is difficult for some patients ... and is especially so for diabetics, where poor sugar control and high blood sugars can independently drive thirst ... and as a longer dialysis duration clearly assists the time-dependant-transport and removal of molecules like phosphate, B2-microglobumin, homocysteine etc in addition to the benefits it brings for slower fluid removal rates, then clearly the best option is always, always going to be longer dialysis.
    Last edited by John Agar; November 3, 2015 at 08:44 PM.

  9. #9
    Join Date
    10-25-15
    Posts
    13

    Default Re: Blood pressure fluctuations during hemodialysis

    Thanks again Dr. Yes, she is diabetic which caused the kidney failure. Her blood pressures have not been under good control lately where she has to take 3 different medications for managing blood pressures. Very often, her potassium gets high (around 6-7) and she has to go to the ER to get rid of that. Other than being diabetic, she has anemia, hypertension, severe cramps (which is related to pulling fluids too fast?), nausea almost everyday and severe leg, body pains. She gets really worn out especially after dialysis. It is very hard to convince the techs at dialysis to pull at a slower rate, we tried so many times with no luck and I am depressed. Lately, we are very stubborn in not letting them set the UFR above 800 while they use to run with 1000 or even 1300 before. So let's say, if we run with a UFR of 600, would they need to adjust the electrolyte baths which pulls potassium, sodium, etc., as well? Usually, they set the potassium bath to 2 I believe.

    Btw, I completed reading all of the URL's you posted and subscribed to the blog. I am eager to know about HDC, although, I am not sure if they will implement that in the US. Thanks.

  10. #10
    Join Date
    11-17-09
    Location
    Geelong, Victoria, Australia
    Posts
    467

    Default Re: Blood pressure fluctuations during hemodialysis

    I am afraid that I am NOT your mother's nephrologist, nor do I know her case.

    While these message boards have long been useful for giving generic information to patients and/or their carers about dialysis issues, they are not, cannot and are not intended to replace your mothers general practitioner nor her specialist physician(s) or her managing renal or dialysis team.

    While I understand your anxiety over your mothers situation, I am afraid that I am not able to discuss nor give any advice about her specific care. It seems to me that you need to seek a time with her treating team, to acquaint them with your worries, and let them explain her care to you.

    You may also derive some comfort and reassurance - or some 'I've been there, and done that' advice and explanation from other patients and carers through the Home Dialysis Central FaceBook page ... just type into the FB search box the words 'Home Dialysis Central Discussion Group' and let them know that I suggested that they might be able to help you.

    I hope you will understand that as I am not your mothers physician, I cannot make specific comments about her management.

Tags for this Thread

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •