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!
© … 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!
DROP her dialysate temperature to proper cool dialysis (35.5)
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!
REDUCE her target weight by 0.25 kg every second treatment
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.