April 2006' Neph. News & Issues Article

I hope I don’t get nailed for jumping into the fray because people are obviously quite passionate about the machine they use. I haven’t used either machine, but have heard and watched company personnel show how both work. I’m impressed by both as well by other machines that are not mentioned as much or that are coming down the pipeline.

I think the article was well written and described the process that their clinic used to evaluate patients and machines. They talked with patients who used both machines and DC said in his post that he talked with a patient who had used both the Aksys and NxStage machines to help him gain perspective in writing the advantages and disadvantages. His article made one very important statement that I think is being overlooked: “No one system can be right for everyone. There are advantages and disadvantages, depending on the patient, facility, and home setting.”

Different people look at things differently based on their own needs. When we developed the advantages and disadvantages chart on treatment options on this site, Dori and I knew what some might consider an advantage, others might consider a disadvantage. The same is true for the advantages/disadvantages of machines.

We don’t believe the key is to promote any specific machine because that might limit patient choice. We believe the key is to promote home hemodialysis as a modality, to encourage development and use of more user-friendly machines, and to encourage facilities to evaluate each patient’s situation and seek input from the patient on choosing the machine that will work best for the patient and facility.

In a perfect world, patients would be able to get exactly the machine that they want. However, getting a dialysis machine is not like buying a car. When you’re buying a car, you look at Consumer Reports, check out what others are saying on the Internet, talk with your friends, and test drive cars to find the one that you like the best. You may not always be able to get the car with the most bells and whistles because your budget limits that.

The same is true with dialysis machines. Insurance (Medicare and commercial) reimbursement affects what options may be available. If you’re in the U.S., look at postings from those in other countries who don’t even have some of the choices that people in the U.S. have. They may have other choices that people in the U.S. don’t have.

Hopefully reimbursement barriers in the U.S. will start coming down if the latest bill (H.R. 5321) that was introduced last week is passed. If you live in the U.S., you can help promote that by contacting your representatives to ask them to co-sponsor this bill by accessing the Legislative Action Center from the home page of Home Dialysis Central.

Funny Bill, seriously though, maybe sometime you can stop in and see someone with the NxStage and see the set up etc. It would certainly be perfect for you, our traveler, although it still doesn’t work for international travel unless you ship your own supplies.

I don’t think I’ve been brainwashed, nor do I think NxStage users are any more “militant” than anyone else. It simply is such a simple little machine, especially after learning a much more complicated one. I think that may be part of it, many of the more “vocal” NxStage users have used other machines so we see the difference.


I have seen the NxStage and talked to people while they dialyze that’s why I felt the comparison was about right - it’s hard to understand why pointing out a couple minuses - I mean of course priming a new line each time takes more than one step.

What does the initial rollout issues the PHD had have with the two machine’s design? The things you guys are quibbling about - 44 or 100 steps - pales compared to the main difference: Dialysate and dialysate flow rates.

Did you read the article?

And Gus when you choose to mention the amount of time it takes the PHD to manufacture 50 liters of ultra pure dialysate or disinfect the blood circuit increasing the PHDs biocompatability you should also choose to mention that these processes are designed to require no involvement on the part of the dialyzor. When I am at work it makes me happy to know that my PHD is using our time apart to my benifit.

Did you read the article?

And Gus when you choose to mention the amount of time it takes the PHD to manufacture 50 liters of ultra pure dialysate or disinfect the blood circuit increasing the PHDs biocompatability you should also choose to mention that these processes are designed to require no involvement on the part of the dialyzor. When I am at work it makes me happy to know that my PHD is using our time apart to my benifit.[/quote]

Perhaps that may hold true in another sense, but its still debatable. The article itself is baseless as it make people who know nothing about dialysis machine merely believe that NxStage System One is not the way to go so they have a no other options but to believe what the writer wrote.

The article causes confusipn for those who are trying to decide. A good writer avoids those pitfalls. :smiley:

As mentioned in the article, the “disadvantages and advantages” chart was a result from your fellow home hemo patient’s experience with both systems. The patient is currently on the NxStage and is VERY HAPPY to be on the system, even with the given disadvantages that he cites. I don’t know how it would confuse anyone deciding what options would work and not work for them by giving both details of pros and cons. If only a positive perspective is given, a decision may be made and regrets may be realized after time and energy has already been expended because of an overlooked issue. Individual conclusions can be reached by applying the given disadvantages/advantages and relate it to the restrictions that may exist in one’s home setting.

Look closely, its like comparing a diesel truck with a subcompact… :?

Please compare two portables…that makes more sense.

Where’s the Analytical learning curve chart? :?

NxStage was compared to Aksys. As far as disadvantages of NxStage some of the following were listed:

> Computer display is not user- friendly, open to operator interpretation

> Some tx. adjustments during tx. are difficult and leaves operator uncertain about accuracy

> Preparation for tx. is complicated (almost 100 steps)

> Errors are very difficult to correct once tx has started

Can you explain more specifically what the patient meant by his above statements? Also, re AKSYS PHD System advantage list the first statement was:

> Sophisticated technology benefiting the quality of tx.

Means what???

After reading all have decided I’ll decide for myself lol My point of view is that I’ve waited far too long already and that I’m glad for the chance to use ANY machine at home. I don’t think we have access to the perfect machine yet, but know that in the US it’s all about supply and demand. If more people see those on home hemo doing really well more will want home hemo; that will “inspire” inventors and engineering types to create a more perfect machine, or to perfect the ones already on the market. That will be a big plus for all home pts…, and all those wanting to be a home pt… Someday soon there will be a 10 step machine, that sets itself up, folds neatly into a storage pouch, and is light enough to take as a carry on peice of luggage ; it’s in my dreams for now but who knows what will happen tomorrow.
The article was ok but not that great because it only contained the viewpoint of one pt… so it’s just insignificant in my book. Lin.


NxStage was compared to Aksys. As far as disadvantages of NxStage some of the following were listed:

> Computer display is not user- friendly, open to operator interpretation

> Some tx. adjustments during tx. are difficult and leaves operator uncertain about accuracy

> Preparation for tx. is complicated (almost 100 steps)

> Errors are very difficult to correct once tx has started

I don’t understand the display not being user friendly. It is color coded and has pictures, my 11 year old son figured out what almost everything meant just looking at it the first time. Again, not sure how it is open to operator interpretation. I would love more detail on that. It gives pressures, dialysate flow, fluid removal speed, blood flow speed, what is confusing or open to interpretation??

What adjustments are difficult and leave operator uncertain about accuracy?? I can’t think of any.

What almost 100 steps unless you count loading the cartridge as 20 steps:

  1. Tear open package
  2. remove lines from cartridge
  3. remove tapes from cartridge
  4. open machine
  5. insert cartridge
  6. attach arterial pressure line
    7.push in first line
  7. push in second line
  8. push in third line
  9. remove saline cap
  10. remove saline post cap
  11. insert saline line in saline
  12. push line in completely
  13. close machine
  14. push prime button

Okay I only came up with 15, but I probably could have made more, to me this is one, or two steps at most. Then I insert the dialsate bag in the heater and attach the lines to the bags, break the bags and prime the lines and remove excess air. Done until prime finishes, so I pull tapes, draw heparin, take pressures and temp, get weight and wash, grab a drink and snack, when prime is finished, I get the air out of the saline line, attach it to the saline, attach the dialysate line, attach the waste line, and connect the blood lines (not necessary but makes it easier for me), set the machine for blood speed, dialysate speed and fluid removal, insert needles and press start (green kidney button). One should also note that waste lines are color coded with yellow clasps, arterial with red, venous with blue and saline with white, any idiot can figure it out.

Now where are 100 steps?? What am I not doing??

How are errors difficult to adjust?? What kind of errors? I can easily change any parameters. Error messages are easy to fix, Again I need specifics, but wonder seriously about the person interviewed if this is truly how he feels.

I could care less about which machine he/she prefers, however, I do not feel as if this is accurate. Bill points out that the method of dialysis is very different, that is true and if he feels that his dialysis is better with the Aksys then that is important to him. I go by my numbers, and even as a big girl over 100 kilos, my last KT/V was over 2 with the NxStage, and everything was normal, including b/p. I do take binders, but needed just as many on the Fresenius, so have noticed no difference.


I dont really think its all that important how many steps there are to setting up a machine. Theres a fair few steps to my machine, but its not hard to set up. Time consuming maybe, but once you learn it, its a peice of cake.

Absurd, sham, fake…[/quote]

Gus I’m not sure what part of that you think is inaccurate but it looks about right to me - at least from what I have seen.

“Computer display is not user- friendly, open to operator interpretation”
Doesn’t the NxStage display error messages along the lines of “E3” and you either happen to know what “E3” means or you have to look it up in a book? To me the NxStage display is clearly not as easy to understand or as unambiguous as the PHDs conversational display.

" Some tx. adjustments during tx. are difficult and leaves operator uncertain about accuracy"
Is this a reference to changing the target fluid removal? Changing the target fluid removal on the PHD is very clear and literal.

" Preparation for tx. is complicated (almost 100 steps)"
Stringing the machine is always going to be more involved than changing the transducer and pushing a button. How one would count the number of steps involved could be open to debate. How detailed is each step? But the PHD sets a high bar.

"Errors are very difficult to correct once tx has started "
I would have to know which type of errors this refers to but in general changing the treatment length or fluid to remove is very simple, routine on the PHD.

What is your beef Gus? The article or at least Jane’s post didn’t even mention the clinical advantages/disadvantages. These convenience issues/ ease of use issues are less important. Biocompatibility is the key IMO

Oops-- I edited some extra lines out of the above post, but it was from “Guest,” not me.

Aha, editing someone’s post…hmmm :?

Sometimes Dori and I go into messages to remove extra lines so more messages fit on a page. I’d appreciate it if posters would have only one blank line between paragraphs. This way messages will be tighter, people won’t have to page through so many pages to read something, and Dori and I won’t have to edit out blank lines. Thanks!

Exactly! Also, the “quote” function automatically adds a line after, so there’s no need to skip a line after it. The only other thing I fix is names if I see that they’ve been misspelled. Other than that, y’all are on your own. :smiley:

Well now that I have spent three weeks with the System One (and this week four years with the PHD) let me say that the above is completely true - no ifs, ands or buts.

This article talks only about the ease of use, not the clinical impact of the two machines. This article does not compare the NxStage to three day a week incenter or home dialysis on another machine - it’s just compared to the PHD and now that is a mute point because of the PHD’s limited availability. However, I’m still a PHD user and it’s available in some locales: Seattle and London at least, not sure where else so in that regard this thread is still relevant. However, it is relevant in another way: I have to say that those of you who were just horrified by the implied criticisms of the article should ask yourselves why you had such a strong reaction? I’m not sure I understand what is going on here but the criticisms in the article and this thread are mild and inconsequential compared to my clinical observations that I will post separately.

You System One dialyzors are using a new machine that relies on novel processes, as I am with my day to day use of the PHD. The NxStage is not the end of the 60+ years of hemodialysis machine history, any more than the PHD was, it just one more step to a future I cannot imagine. The posters on these boards are all moving the ball forward to eventually reach the unimaginable and I am sure brighter future but as we do this let’s be clear eyed.

For what’s it worth, here’s my take

> Computer display is not user- friendly, open to operator interpretation

The PHD has a full graphical user interface with touch screen controls. At a glance I can see the dialysate temperature, the conductivity, treatment time remaining, the time of day, amount of fluid removed, arterial pressure and venous pressure. These are continually updated in real time as the treatment progresses. The screen also presents generally static settings e.g. Qb, Qd, UFR and total fluid to remove. There is also a continuously updated line graph showing the arterial and venous pressures over the last thirty minutes.

There is a “Tools” button on the touch screen that brings up sub-menus with options to see dozens of real time sensor readings, and sub-menus presenting information about the particular treatment and recycle information. There is also a “Modify Treatment” button on the touch screen that brings up a sub-menu that shows and where I can change Qb, fluid to remove, Dialyzer backflush interval, Treatment length and dialysate temp.

On the PHD all the readings are labeled in conversational English. To determine the UFR and fluid removal goal I simply enter my pre-weight the machine does the rest based on the treatment length. If there is an alarm the machine describes the alarm and the recovery steps in English no need to consult a manual. The System One asign a number to each alarm which you either know or have to look up in the manual.

Compare that the System One (as seen here http://video.google.com/videoplay?docid=-1749639265679650272 ). The largest displayed settings are static Qb, the hourly UFR and the hourly amount of dialysate being used (in the video the 8.6 liter per hour dialysate use rate translates to a Qd of 143). The readings one cares about: arterial and venous pressures and the big question, how much treatment time is left are scrolled through in a single, tiny display.

This is weird. If I am having needle problems I want to see the pressure reading continuously displayed as I adjust the needle, I don’t want to see three snapshots of the pressure before the scroll goes on to another number. When I dialyze I am regularly glancing over to see how much time is left, again with the System One I have to catch it on the scroll. Why not scroll the static settings and display pressures and time left in large continuously updated display windows? Because the seemingly static settings are the only things you can adjust during treatment, more on that to come.

On the System One the dialyzor not only has to calculate their fluid removal goal (plus rinse back), one has to also figure the UFR! Now I love math so it was no big deal but compared to the PHD the system relies much more on the dialyzor to get things right, it is clearly “open to operator interpretation”.

> Some tx. adjustments during tx. are difficult and leaves operator uncertain about accuracy

During treatment on the System One if you want to lower your Qb you have to first lower your hourly dialysate flow rate. If you want to change your Qb from 400 to 350 you’d have to first lower the hourly dialysate use rate by some amount “open to operator interpretation” and then see if the machine would allow you to reach your Qb target. On the PHD you directly control Qb on a sub-menu. When the PHD restarts after an alarm (e.g. a needle pressure out of range) it automatically restarts at a Qb=100, on the System One it is not clear what Qb is during recovery, in fact Qb cannot be changed until a given alarm is recovered.

If you want to change your treatment length on the System One you can’t, you can game the treatment length by increasing Qb but if you really wanted to come off an hour early for whatever reason the only option is to force the treatment to end which leaves dialysate unused and you’d have to guess how much to increase the UFR to reach the target. With the PHD you just change the treatment length, the UFR automatically adjusts upto a pre set UFR maximum.

> Preparation for tx. is complicated (almost 100 steps)

There are more steps, how many would depend on how one parses the process. There are about 8 critical steps where the dialyzor is making a sterile connection on the System One - including attaching each dialysate bag to the circuit, the other dialysate connections and the needle lines. With the PHD there are three: of course the two needle lines and the very first step replacing the transducer. Time wise, hands down the PHD is faster, compared to the System One there is no pretreatment preparation time.

> Errors are very difficult to correct once tx has started

How do you change the target fluid removal goal on the System One if you make a mistake weighing? e.g. forget to account for the sweatshirt you’re wearing or decide to have a drink. On the PHD you just change the goal on the modify treatment sub-menu

I think I react so strongly because it makes the NxStage seem like a difficult machine, it isn’t, maybe the Aksys is easier to use, but it certainly doesn’t seem to be a hit with clinics and most users as they have fewer and fewer each month than NxStage.

With regard to a couple of your statements. Yes some things scroll but you can set the length of time the scrolling takes, mine only takes a few seconds, no biggie and it was easy to get used to.

With regard to calculating goal plus rinseback, there is a machine setting that will automatically take off any fluid the machine gives you.

With regard to changing your goal during treatment, it is easy to increase or decrease it by hitting the arrow key. If you increase you may have to increase your hourly rate depending on whether you are trying to time them to finish at the same time. I usually take off quickly and then run without u/f.

Again, this may be more complicated than the Aksys, but you have to admit you learned it in a few days and felt comfortable enough to drive 2000 miles from your center. This is what is important.

home hemo 9/04
Freni then NxStage

It must be tempting to conflate the business model of the PHD with its usability or clinical effectiveness. The NxStage’s great innovation is the service plan where the machine is switched out. Aksys, in my opinion, suffered from too many people involved in the design of the PHD, it became too complicated. But in fairness, the complications are in service to optimal clinical outcomes. The problem is that understandably, no one wants their dialysis machine to be the least reliable piece of equipment in their home. The PHD suffered from uneven reliability, if all PHDs preformed as well as mine the company may have been able to achieve their business model/goals.

The question the initial post addresses was which is easier to use day to day, as designed. Which design ends up being easier to use as intended, over time. The question was not which is easier to learn, speaking for myself I learned both in the same amount of time. Over time, especially for self dialyzors the PHD is easier.

As far as the fluid calculation NxStage provides a table to assist the calculation of the hourly UFR. I too am able to do the calculations in my head but again compared to the Aksys the article was accurate.

And yes of course my post is in the context that I am willing to use the System One. I think the System One is safe and a good choice over incenter three day a week dialysis. I think the NxStage System One is easy to use, on par with the B Braun Dialog (the only other machine that I have used at home other than the PHD). I think it is much easier to understand the System One by comparing it to a FMC or other standard machine. Cathy, I think you have posted that take away FMC’s water treatment and they are about the same.

What I find remarkable is the reaction that the article received. I worry that there is too much partisanship. That to admit a short coming is to admit failure. I worry about the schadenfreude I read between the lines of some posts in the cyber world and schadenfreudenistic actions in the real world.

I’ve heard it speculated, from a number of sources, that an Aksys competitor alerted the FDA to the disparity between the PHD’s 510k and their move to longer treatments - including nocturnal - that resulted in the recent warning letter. If true I ask: was that done for the benefit of dialyzors? or was it the result of competitive business juices? I understand the requirements of business - stockholders and stakeholders - but this is not a case of competing espresso stands “let the best latte win“. This is about real people and their renal replacement needs. I think whoever dropped a dime on Aksys made life harder for many people without achieving any great or required business victory.

Maybe it is the non-profit bubble I live in here in Seattle but I do not see the benefits to dialyzors of competitive hardball business tactics. And I wonder if the competitive business environment is compromising our interests - the interests dialyzors. I certainly have reasons to say nothing. I’m satisfied with how the Northwest Kidney Centers presents the NxStage and the level of information I received during training. After all I’m just one dialyzor and I could let the conventional wisdom of those on the System One stand.

But that is not the path I have chosen. I choose to seek to understand how dialysis works and the compromises we dialyzors must make. It is a balance. I try to stick to posting my personal experience, as accurately as I can. I think I have done a pretty good job, I can think of only a handful of HDC posts I would retract or I wish I had not written or that I had written differently. Now I have to accurately write my clinical impression of the System One and I am a bit gun shy, I am not sure how to present my opinion. Is that good? Should we only write the positive?

I write for myself. I try to say what I would like to know if I was coming to this board at a different stage in the journey or if I was in a different situation. I know that I am in a unique situation - no one has my exact options. My goal is to accurately describe my experience, for what that‘s worth. As far as what motivates me - part of it has to be ego. I like the challenge of writing clearly about a complicated topic and I get a boost from positive feedback about my writing or turn of a phrase. But I also think I am helping the situation by challenging what it means to be a dialyzor. I want people’s world view of dialysis to include me - I am proof that I am possible.

Part of my approach is that I strive to be humble and skeptical. I fully admit that what we take as fact today may well be proved incorrect tomorrow. I’d just like to see that same humility and skepticism in others. I may be wrong but what I write is what I think to be true.

I think you gave your personal opinion based on what you experienced, but am surprised how quick you learned in four days and hit the road for your great journey! Didn’t you take longer to train on Aksys?

Anyway, in most cases simple solutions are the best solutions and the one and most important aspect of daily dialysis at home is the freedom…

The only thing I care is that our dialysis machine companies open up their eyes and try to understand what we patients want in a home dialysis machine…I think NxStage has gotten the whole idea and plan and I think Aksys’s new portable is a good evidence that follows that trend.

Now the question is how will Aksys’s new portable differ from NxStage’s System One? :?: …time will tell but am really interested to know, its better to compare two portables and not of the large standard size dialysis machines with a portable…

Thanks for the feedback on this Bill, it will help better design of home dialysis machines… :slight_smile: