Bad patch

Ask Our Experts Dr. John Agar, Nephrologist
1

Hi

I am Ray and hve been a member of this site on a different computer ans e-mail address.
I have been on dialysis since mid May of 2006. I started home hemo on June 1st 2007 and would not go back to in-center for treatment period. My kidney failure is due to 36 years of diabetes. I was on the kidney/pancreas transplant list until my yearly stress test last september showed I had a heart attack. After a quadruple bypass surgery, November 6, 2009, my right mid arm a/v fistulla failed. The next day I had a permacath placed in the left chest area. This cath ran fine and on January 4th 2010 I had a new fistulla placed in my left wrist. I have since had 3 procedures to help develope fistulla including rerouting it. My dialysis team ans I have abandoned the fistulla because it would not mature. On July 7th I had to have my chest catheter removed due to infection and had a new one placed in the left side of my chest. We had some difficulty running the cath. and could usually run it backwards and get a 500 blood flow. July 30th was my last full dialysis treatment due to the infection that apparently never went away. I was admitted to the hospital July 31st. aaaaaaaathey pulled the infected catheter 2 days later and started me on several iv antibiotics. On the 9th day of my hospital stay the Infection specialist okayed placement of another chest cath. It was placed Monday August 9th and i was sent home to dialize, along with orders to go to a local hospital for iv antibiotics every 48 hours til September 1st. As soon as I got home we set up my nxstage cycler and got ready to run dialysis. After hooking up to the machine my blood never even reached the cycler because the arterial pressure was over 400. We tried 6 more time over the next couple of days with the same results. On Sunday the 15th of August we were able to run for 1hour 14 minutes at a blood flow of 150 until my blood clotted. I will say that during this week at home my dialysis nurse was trying to get me into the hospital for a catheter replacement , but theey would not return his calls. Monday the 16th I went to my nephrologist office and he got on the phone and literally tore into the hospital staff who told me to get there right away to fix the problem. I had a replacement catheter in the same place within 2 hours and it was filled with alcavia(?) We went home and set up the cycler to run. I am only getting a 310 blood flow with this new catheter even after 2 treatments. My wife thins the diameter of cath tubes into chest are smaller than my earlier catheters. I am used to running dialysis for 2 hours and 20 minutes with a 500 blood flow. Currently My dialysis time is almost four hours.
I need to know if it just takes several treatments to get catheter flowing better or if the smaller diameter cath will only run in the 300+ ml/min blood flows. Does anyone out there have experience with this? My Nephrologist said Thank God you still put out 1000 liters of urine a day. I am scheduled to have a new midarm fistulla placed in left arm on August 27th (god willing and infection gone) Someone please share your knowledge about this problem with me. I am feeling very ill and anxiouse and would appreciate any advice and or prayers.

ray harris

2

Oh Ray … this is a hard one.

I would love to be able to help but I am really only likely able to make one or two observations and probably not be as helpful as you’d hoped.

It seems all was going well till your ® arm AVF failed. Concurrent (and major) vascular illness … and a CABG is one such - with all the ICU stuff that follows etc … is a common destabilising factor in vascular access and it seems you lost your long-term ‘friend’ about then. Sadly, that’s not uncommon … and its sometimes unavoidable, though I don’t know the specific circumstances.

Since than its been a struggle - for you and your team - and I wish I could say the same never happens here … but it does! We all try hard (team, patient, surgeon, the lot) … we try all sorts of stuff, of ‘solutions’, catheters, replacing catheters, new AVF which then don’t work as we want them to … argh!

All I can say is that I have ‘been there’ with so many patients and its so frustrating … so frustrating … and demoralising too.

Yours is not an uncommon saga.

All I can say is … stick with it. Just keep, with your nephrologists and with your vascular team, ‘plugging away’.

A lower flow catheter (Qb +/- 300 ml/min) isnt the end of the world! Here, in Oz, our catheter flow rate is a mean of 300-325!

500ml/min! Ye gods … we actually never run at that … I have no experience of such flows! never! ever!

And, that’s not 'cos we couldn’t (if need be) … though we tend to use smaller ‘bore’ catheters here than is common in the US (and we avoid catheters at all cost anyway). We dialyse longer. And longer dialysis doesn’t need that sort of bazooka flow.

As for ‘bore’ … flow through a hollow tube is inversely proportional to the radius to the power of 4! That’s physics … see: http://en.wikipedia.org/wiki/Hagen–Poiseuille_equation.

So … smaller catheter, smaller flow. But you ARE now getting about 4 hours … whoopee do! Hooray! = a half decent dialysis time at last! So, 300 ml/min for 4hrs+ while your AVF is being sorted? That’s fine … or should be.

So, don’t stress too much.

Get the AVF sorted as best you can. Make sure your dialysis hours DON’T contract … 4hrs+ is your goal!

If any benefit has accrued … and believe me, it has … it’s the rise in your dialysis hours … and, by default, that may be the biggest benefit of all!

Work with your team to resolve the AVF problem … but meantime, keep your hours up. Flow? … not an issue. Hours? … yes! And, as I said, by default, you’ve got to better dialysis … and you didn’t even know that you had!

Cheers

3

Dr. John,

Thank you for your experienced insught in my problems. I have a dete set for a new fistulla placement and hope my body cooperates with it. Every sisnce I have started homehemo our target dialysis time has been 2hrs 20min. I have not thought I would benefit from longer runs, until I read your reply.

Again Thank you

Ray Harris

4

Hi Ray,
You may want to read some articles Dr. Agar has written for us on this very topic. You can find them here:
– http://www.homedialysis.org/resources/tom/200711/
– http://www.homedialysis.org/resources/tom/200712/

Dialysis is not just about waste removal–gentle fluid removal is much easier on your heart. But if you find (as I suspect you will) that 4-hour treatments + set up, take down, clean up, supply ordering… take too much time out of your day, you may want to ask your care team about doing nocturnal treatments. There, a slow blood flow is no problem. You’d want to use a bedwetting alarm pad under your catheter and under the dialyzer (even a drop of fluid will set these off, so you can sleep with less worry). You’ll get MUCH better dialysis–and have your days free.

5

hi Ray,
sometimes the universe just doesn’t seem to give a guy (or a gal) a break. My knowledge base isn’t gonna be very helpful I’m afraid, so I just thought I’d let you know I’m thinkin of you, and I’ll do the prayer bit. These days I’m not really sure if God exists!, but until I’m sure he doesn’t I continue to have words with him. So a prayer for Ray tonight.
Take care,
Good luck,
Sinead

[QUOTE=v.ray harris;20062]Hi

I am Ray and hve been a member of this site on a different computer ans e-mail address.
I have been on dialysis since mid May of 2006. I started home hemo on June 1st 2007 and would not go back to in-center for treatment period. My kidney failure is due to 36 years of diabetes. I was on the kidney/pancreas transplant list until my yearly stress test last september showed I had a heart attack. After a quadruple bypass surgery, November 6, 2009, my right mid arm a/v fistulla failed. The next day I had a permacath placed in the left chest area. This cath ran fine and on January 4th 2010 I had a new fistulla placed in my left wrist. I have since had 3 procedures to help develope fistulla including rerouting it. My dialysis team ans I have abandoned the fistulla because it would not mature. On July 7th I had to have my chest catheter removed due to infection and had a new one placed in the left side of my chest. We had some difficulty running the cath. and could usually run it backwards and get a 500 blood flow. July 30th was my last full dialysis treatment due to the infection that apparently never went away. I was admitted to the hospital July 31st. aaaaaaaathey pulled the infected catheter 2 days later and started me on several iv antibiotics. On the 9th day of my hospital stay the Infection specialist okayed placement of another chest cath. It was placed Monday August 9th and i was sent home to dialize, along with orders to go to a local hospital for iv antibiotics every 48 hours til September 1st. As soon as I got home we set up my nxstage cycler and got ready to run dialysis. After hooking up to the machine my blood never even reached the cycler because the arterial pressure was over 400. We tried 6 more time over the next couple of days with the same results. On Sunday the 15th of August we were able to run for 1hour 14 minutes at a blood flow of 150 until my blood clotted. I will say that during this week at home my dialysis nurse was trying to get me into the hospital for a catheter replacement , but theey would not return his calls. Monday the 16th I went to my nephrologist office and he got on the phone and literally tore into the hospital staff who told me to get there right away to fix the problem. I had a replacement catheter in the same place within 2 hours and it was filled with alcavia(?) We went home and set up the cycler to run. I am only getting a 310 blood flow with this new catheter even after 2 treatments. My wife thins the diameter of cath tubes into chest are smaller than my earlier catheters. I am used to running dialysis for 2 hours and 20 minutes with a 500 blood flow. Currently My dialysis time is almost four hours.
I need to know if it just takes several treatments to get catheter flowing better or if the smaller diameter cath will only run in the 300+ ml/min blood flows. Does anyone out there have experience with this? My Nephrologist said Thank God you still put out 1000 liters of urine a day. I am scheduled to have a new midarm fistulla placed in left arm on August 27th (god willing and infection gone) Someone please share your knowledge about this problem with me. I am feeling very ill and anxiouse and would appreciate any advice and or prayers.

ray harris[/QUOTE]