Are consecutive txs better?

Dr. Agar,
I would like to know if doing consecutive txs provide better clearance then breaking the txs up. For ex, lets say ones prescription calls for 6 tx per week. Is it better to dialyze 6 nights in a row and then skip a tx, or is it just as beneficial to dialyze 3 nights, skip a tx, and then dialyze 3 more, or some such other pattern as long as one gets a total of 6 txs in per week?

[I][B]You asked:

Is it better to dialyze 6 nights in a row and then skip a tx, or is it just as beneficial to dialyze 3 nights, skip a tx, and then dialyze 3 more, or some such other pattern as long as one gets a total of 6 txs in per week? [/B][/I]

In a word, the answer is a qualified ‘yes’ … but while I believe that ‘more is better’ and I also believe that ‘the more often, the better’, one has to be realistic. Dialysis is more than just its ‘prescription’.

Why ‘qualified’? … well, though I have explained this in detail in these pages many times: the fact that frequency only benefits solute removal and not fluid removal and volume control if, by dialysing more frequently, the dialysis time for each session is coincidentally significantly reduced - such that total hours per week are essentially the same. This seems the most common pattern in the US. Higher frequency only benefits volume status if dialysis time is not correspondingly reduced by a half - as is the temptation and tendency.

All this has been explained before - and can be found in detail and replayed at (1) the Webinar titled ‘How Dialysis Works: Fluids’ - which can be found towards the bottom of the HDC home page … or can be studied and understood at your own speed at (2) my website under both ‘Dialysis Choices’ and the ‘Dialysis Issues’ buttons.

However …

In my view, dialysis must be designed/tailored to lifestyle … to achieve ‘the best lifestyle outcomes possible’ for any one individual. Although that doesn’t always result in ‘the best dialysis’ … though I’d prefer it to … reality strikes. Idealism is good - and works for some, but it doesn’t cut the mustard for many. Many of us might, privately, regret that … but practicality and pragmatism are powerful forces and, for many, dictate what we do. In the end, dialysis should return the maximum ‘lifestyle’ … for each individual patient … that that patient wishes within their acceptance of the dialysis cage in which they find themselves. Not that we shouldn’t try to alter their perception or acceptance of their dialysis boundaries … I actually believe that we should: why else would I write these pages?

But, lifestyle is what each of us makes it … and dialysis should always be a means to an end to enhance it.

‘Lifestyle’ is a furry word. ‘Lifestyle’ means different things to different people. What one dialysis patient may want, for him or herself, out of his or her ‘life’, may be a quite different goal, a different aspiration from the needs and/or the wants of another dialysis patient. ‘Lifestyle’ may mean quality to some. It may mean quantity to others … it comes in many guises.

In the end, dialysis should be designed for the individual - and that is why I am so vehemently against the concept of ‘one-size-fits-all’ conventional dialysis … even though, with sadness but with realism, I and my unit do what all other nephrologists and other units do - and that is: conventional dialysis.

At least we try to offer a range of therapies to fit all needs … and that’s better than not trying at all. But, and at the end of the day, only 35 of our 114 HD patients are at home on flexible overnight ‘as they wish and want’ self-care dialysis regimens.

But, that means that 79 of our 114 HD patients … we, of course, have an active CAPD/APD program as well but I am just talking HD here … 79 of our 114 HD patients are facility-bound.

These facility patients get between 4 and 5 hrs x 3 sessions/week - and yes, and to my shame, we have not eliminated the long break with a facility-based rolling alternate regime. Much as I would prefer to do so (and ‘preach’ that we should), the obstacles are many, and I am but ‘me’.

Systems: funding, nursing unions, nursing expectations, state regulations … whatever … are powerful beings and not easy to turn - not just like the Titanic but like a brace of Titanics!

But, even in our facilities … we do try!

We offer 4 - 5 hr x 3/week dialysis, we offer 2.5-3 hr x 6/week short daily … we do try.

We do try to tailor the best we can - given the expectations and limitations placed on us - not only by the system but by our patients too. Some (no, many) choose not to have more frequent dialysis when we suggest it would be to their benefit. Some choose not to go home when we clearly think (and advise them) that they should. There is a saying … you can lead a horse to water, but you can’t make it drink!

For those who do avail themselves of our more imaginative, individually scripted programs, again … it comes down to individual choice of: dialysis vs lifestyle!

You can’t do much, when you are on dialysis. You can only do, when you aren’t.

So, more is better and more often is better has to be tempered by how much is acceptable … for the individual … and for that individual’s lifestyle aspirations and expectations!

It’s a ‘trade off’. Each patient must make it - as it suits them, their family, and their needs!

Personally, I think more is good and more often is good and every night is best … but: damn it, let’s say it once and for all, optimal dialysis - should we ever reach it - would be continuous!

But, given current systems and equipment and options (and excluding PD) … that’s next to ridiculous.

So … we ‘approximate’.

We get as close as lifestyle expectations and aspirations allow … for that individual.

Now … for some, that might be every night (but most can’t hack that - nor ever will).

So … for others, a serial six nights on and one off is acceptable ( and we have a few prepared to do that).

And … for others, it might be 3 nights on and one off.

And … for others (say, a shift worker) it might be 4 nights of 7 one week and 5 nights/of 7 the next week.

Or … for a person who usually does a 3 on : 1 off : 2 on : 1 off regimen (and many of our patients follow this program), there may be a wedding, or an ‘event’ that alters their strategy … Good! say I … let it!

Finally … there are others who will only accept and ‘do’ (as their lifestyle choice) alternate night long-hour treatments - and this is the regimen that applies to the majority of Australian nocturnal patients who, most commonly do 8-9 hours on alternate nights (7 nights in every 14) - but even then, in so doing, they protect themselves from the greatest risk of them all - the dreaded ‘long break’.

I encourage my patients to live their lives … not to be bound by strict rules and programs. They all know that I believe that ‘more is better’ and ‘more often is better’ … but that I also believe that to be a functioning human being is more important - and that dialysis is, as its prime purpose, a process designed to let those who without it would die … live! Live, as best they can … but live.

So … to answer your question ‘what regimen is most beneficial’?

Within the dictates of ‘more is better’ and ‘more often is better’ … I say, whatever that patient can do, will do, wants to do, and/or is prepared to do.

Does any one regimen laud itself over any other? … No … my advice is: just dialyse as much as you can manage to do and as dialyse as often as you can accept doing … all within the lifestyle and wellness goals that you set for yourself … not that I, as a doctor, set for you … and, in the end, be happy with that and that you gave it your best shot!

Dialysis should be flexible.

Dialysis should be aimed at attaining goals - and these goals are different for every patient. They may be ‘wellness’ goals, they may be ‘biochemical’ goals, they may be both - or more … whatever rocks your personal boat.

But, providing these goals are reached, and to your personal satisfaction? … well, then, I think you have probably achieved acceptably good dialysis - for you.

Only you know your goals … and these are not for some third party - even a well-meaning nephrologist - to dictate.

Individuals set different goals - so treat to those goals - high or low, and that’s all we can do!