Lactic Acid Question

Ask Our Experts Dr. John Agar, Nephrologist
1

Hi Dr. Agar,

My latest battle on dialysis is with lactic acid levels being high because of what the NxStage dialysate bags are adding to me during treatment. My neph. here switched my treatments to every other day and the lactic acid level went back to normal. I thought I was OK but then I wasn’t being dialyzed enough. We changed the flow fraction settings (from 45 to 33) of NxStage so treatments are now 3 hrs and 45 min. instead of 2 hrs and 15 min. Dr has my wife dialysing me 5 tx a week. Then every Mon for about 2 months now, the lab takes lactic acid level and BMP. My liver doesn’t metabolize the lactic acid when treatments are back to back. My neph is trying to work with me to help me stay at home. In-center would add no lactic acid to my body and be a simple solution but I hate in-center. It would also be simple if NxStage didn’t add lactic acid to their sacs. Baby K setup has no lactic acid but it is too big for my room.

I have the labs every week to see how my numbers are. Either my lactic acid levels are high or I’m not getting enough dialysis because my Co2 is low. My neph. keeps playing with what days I do dialysis and the time I’m on treatment. When it’s almost right, my lactic is a little above normal but creeps up a little more weekly.

Dr. Agar, is there any other suggestions I could make to my nephrologist?

God Bless, Tom Shuford

2

Dear Tom

I am sorry to be slow in my response - it is the summer holiday season here and I have been having some ‘go slow’ time.

I am not sure how or if I can help you here. Firstly, we do NOT use the NxStage (a lactate buffered system) in ANZ and so I have little experience with it since deciding after trialling it several years ago not to add it to our home dialysis programs around the country. Apart from a single service in Far North Queensland, to my knowledge few if anyone else has embraced the system in ANZ. As a result, I cannot speak from a wealth of experience of the machine, or any of its dialysate issues.

There is a recent paper from Kidney International … http://www.sciencedirect.com/science/article/pii/S0085253815466657 … that points to some of the issues with lactate as a buffer in patients with liver disease … you note that your ‘liver doesn’t metabolise the lactic acid when treatments are back to back’ … and clearly this may be part of the problem. You dont, however, stipulate any lactate levels , though I am not sure that even if I knew them, I would be able to say with any certainty that these would prove ‘symptomatic’, or how.

Here, we have (1) always preferred bicarbonate as a buffer and (2) use the Fresenius 40008 S single pass dialysis system … NB: the Baby K is far from a baby and has a large footprint … while our S’s are nice and slim with a floor space footprint smaller than the PureFlow system that the NxStage uses. Further, the Nikisso - now widely used in the Asia-Pacific - is slim and simple, as is the Belco, a system which IS in use in the US as a home system. In addition, some of the Chinese systems are small ands slinky, though as these are yet to be used here, I have no dirtect experience with their use and have simply played with them at Industry displays in China, Sth Korea and Malaysia.

When the Quanta SC+ becomes available outside the UK … see my old blog but with a recent update to a question about it only yesterday http://homedialysis.org/news-and-research/blog/83-a-new-kid-ney-prepares-to-blast-off-the-quanta-sc … this may prove a solution to your issues, too, as it is a single pass system, is as smaller as and lighter than the NxStage, uses standard bicarbonate dialysate and doesn’t require either bagged dialysate or a bulky Pureflow-like system. It does, however, need a mini-RO, though this could be be sited somewhere nearby but not necessarily within the confined space you describe.

I am not sure that I have answered ANY of your concerns, but its the best I can provide.

3

Dear Tom

I am sorry to be slow in my response - it is the summer holiday season here and I have been having some ‘go slow’ time.

I am not sure how or if I can help you here. Firstly, we do NOT use the NxStage (a lactate buffered system) in ANZ and so I have little experience with it since deciding after trialling it several years ago not to add it to our home dialysis programs around the country. Apart from a single service in Far North Queensland, to my knowledge few if anyone else has embraced the system in ANZ. As a result, I cannot speak from a wealth of experience of the machine, or any of its dialysate issues.

There is a recent paper from Kidney International … http://www.sciencedirect.com/science/article/pii/S0085253815466657 … that points to some of the issues with lactate as a buffer in patients with liver disease … you note that your ‘liver doesn’t metabolise the lactic acid when treatments are back to back’ … and clearly this may be part of the problem. You dont, however, stipulate any lactate levels , though I am not sure that even if I knew them, I would be able to say with any certainty that these would prove ‘symptomatic’, or how.

Here, we have (1) always preferred bicarbonate as a buffer and (2) use the Fresenius 40008 S single pass dialysis system … NB: the Baby K is far from a baby and has a large footprint … while our S’s are nice and slim with a floor space footprint smaller than the PureFlow system that the NxStage uses. Further, the Nikisso - now widely used in the Asia-Pacific - is slim and simple, as is the Belco, a system which IS in use in the US as a home system. In addition, some of the Chinese systems are small ands slinky, though as these are yet to be used here, I have no dirtect experience with their use and have simply played with them at Industry displays in China, Sth Korea and Malaysia.

When the Quanta SC+ becomes available outside the UK … see my old blog but with a recent update to a question about it only yesterday http://homedialysis.org/news-and-research/blog/83-a-new-kid-ney-prepares-to-blast-off-the-quanta-sc … this may prove a solution to your issues, too, as it is a single pass system, is as smaller as and lighter than the NxStage, uses standard bicarbonate dialysate and doesn’t require either bagged dialysate or a bulky Pureflow-like system. It does, however, need a mini-RO, though this could be be sited somewhere nearby but not necessarily within the confined space you describe.

I am not sure that I have answered ANY of your concerns, but its the best I can provide.

4

Thanks for replying Dr. Agar. I had a clinic visit today and my nephrologist had some more suggestions and a new plan. I have been going to have a lactic acid level every week. About a month ago, my level was a 4.7. When I did every other day it went back to normal. They have since played with the number of treatments per week and the amount of dialysis. Every week, my lactic levels creep up by .1. Yesterday, I did a arterial blood gas. My lactic acid level was 3.6 and the ABG showed my level was not acidotic. For now, the plan is to periodically check my lactic levels and as long as it’s not acidotic and above .4, we’ll continue with the status quo
Today my nephrologist said #1 was the patient’s preference of modality (at home), as long as I am not acidotic. If I become acidotic, the next step is maybe to cut out a TX every other week. Thanks for your time.

God Bless,
Tom Shuford