Conductivity

Discussions for Patients, Family, and Friends HD For Patients
21

Amba,
If my bp starts dropping too low, or if I feel low as I find feeling is more telling (the bp cuff could be loose), I begin cutting back on the goal .1 or .2 at a time depending upon where I’m at in the tx and how severe the unbalance is. Do you do this?

The most I have ever had to cut it back was a total of about .6, and like I said, that is not all at one time, but a point or two at a time.

I have learned that if I guesstimate my goal too high, it throws the balance of the tx. off and the only way to get out of it is to keep turning the goal back a little at a time. I prefer that to taking saline. Saline always makes me feel bad.

What prescription settings do you use with your tx? Until I found a combination that worked for me my txs were uncomfortable.

Also, through this time, have you been on the same machine or different ones? That can make a difference too.

Also, like I said previously, depending on how much one eats, it is possible for weight to stay the same for a stretch and then suddenly jump up .5 or so. It surprises me when this happens. And it’s possible to have food in ones tract that is real weight on the scale not fluid weight.

24

Pierre:

If after going on treatment, it drops to 110 or less, you cannot let that go. It becomes too risky at home where you can’t get immediate help in case of a hypotensive crash. So the procedure is not to stop UF, but rather to infuse up to 400 ml of saline, 200 ml at a time. If that doesn’t bring the BP back up, then it’s time to stop that treatment for that day or night. There’s no point in going on with it. Just forget about it and call the unit the next morning for instructions about raising dry weight.

When you are on a nocturnal tx does the machine alarm when your bp drops too low during the tx…is bp monitored throughout the tx?

25

We don’t monitor BP during the night. We measure pre, then do a first round after starting treatment, then it’s nothing until post treatment.

Pierre

26

Why would you scrap the tx? Couldn’t you just adjust the dw and goal since that is all that will happen if you call the unit the next day? In-center I do my own adjustments with their total blessing.

27

Well, for one thing, when you do that in-centre, you’re in-centre. You’re not on your own at home. There is presumably some amount of help available in centre until the ambulance gets there if you crash. Can you imagine what would happen to a person who crashed at home? Remember that a person on nocturnal is not monitored for BP and can’t respond to any potential symptoms of low BP while sleeping. Since it’s not a big deal to scrap a daily treatment for one night (especially if it’s already a hour or two into the treatment), why take any chances? The perspective when doing short daily is a little different, because BP is checked during treatment and the person is awake.

If infusing 200 ml of saline twice doesn’t solve the problem (and this is the same as if you had increased your dry weight by 400 ml prior to the treatment), then you may have a problem. If you just decrease the goal on the machine when your BP is already too low, that is not going to raise BP. On the other hand, saline raises BP pretty quickly.

Pierre

28

Jane, if my systolic BP drops below 100 and I have the associated symptoms, I immediately give 200ml saline. If I notice a drop, but its not continuing below 100 systolic, I pause the UF, and check BP after a few minutes and act accordingly. If your BP is dropping rapidly, lowering the goal is a waste of time. You need to act on it quickly, lowering the goal will not bring your BP back up if you are “going flat”. Once you have acted on it, of course you then adjust the goal UF. Your UF goal should never be guessed. It is your current weight minus your dry weight, plus drinks during Dx and washback (300ml here). Everything Pierre has said, is the same as we do over here.
Im not sure what you mean by prescription settings?

Queenie, on that particular day I was running at 500/hr. I have also gone flat at 400/hr when I was in centre for nocturnal. There have been alot of incidences in relation to my BP, but it would take me all day to explain it all. I havent been on BP meds for quite some time.

30

Queenie, this isnt the first time this has happened. Each time I have increased my dry weight, but it doesnt work straight away. Over time it sorts itself out, then my BP goes up. So then I reduce my weight. Now its happening again. Because it is inconsistent, we are unsure whether it is related to my weight. I have put on weight, and have adjusted for this, but going by BP, I should be ok with what I think is my dry weight. Have to wait for the nocturnal doctor to come back from holidays to take it up with her.
I was coming off under dry weight too, roughly 200-300mls. So all I do is I still count washback, but I have a drink once Im hooked up. I like to have a cup of tea before bed as it seems to help me settle. So I just dont count this in my calculations. However, it doesnt work in my favour every time. Sometimes I come off a bit over my dry weight. Its not always easy to be exact, bit different on day time treatments.

31

Amba:

Your UF goal should never be guessed. It is your current weight minus your dry weight, plus drinks during Dx and washback (300ml here).

Dry weight does not stay the same. Just because the neph assigned a dw a month ago or even a week ago, does not mean the dry weight stays static. We are always gaining or losing weight. I adjust my dw every tx. going by my bps from the previous tx, how good my appetite was between txs, how fattening the food was I took in, how regular I was, any edema.

As a neph put it to me when I asked him how he selected my dw, he replied,“It’s a guess”. From then on, I requested to do the guessing as who knows my body better than me, and he gave me the job. If I had not taken this role I would of been cramping and crashing, as we call it over here, all the time, because my dw is continually changing and does not wait on the neph to take notice and change.

The second I feel my tx losing it’s balance, I cut 1 or 2 points off the goal. This is a feeling that I’ve learned to detect and act fast. If I waited too long, I would go flat, too. Cutting the goal back a little at a time stabilizes me. It feels much better to me than taking saline. The dw is not set in stone and can only be estimated. I re-estimate it every tx and set my goal accordingly.

It is possible to gain real weight, but not raise one’s dw enough, or set the goal too high. It just takes being off .1 in one’s estimate to throw the balance of the tx off. This happens as it is not possible to always estimate correctly. Backing off the goal always works for me as long as I do it fast enough in repsonse to inbalance in the tx.

By prescription I mean, what is your sodium rate?

32

Jane, its a bit different in centre compared to home Dx. Generally in-centre, patients dont really have much to do with their treatment. Doing it at home, we are in control of pretty much everything. During training we were taught what to do if you are going flat. Of course giving saline is not desired, but once your BP goes below 100 systolic, you really dont have much choice. Reducing the UF when you are already going flat, will not stop you going flat, you need saline. Im sure you would know this. Of course if you just notice a bit of a BP drop, you feel a bit off, but you arent going flat, then of course adjusting or turning off the UF will help, because you probly have reached your dry weight, or are very close to it.

I actually had an episode at home where my BP dropped to 80/40 after an hour or two on the machine. I gave 400ml of saline and it barely scratched the surface. So I had no option but to discontinue Dx. When I came off, my BP came up. Which is why Im sensing something fishy going on.

My dry weight has been pretty stable, apart from when I gained weight after starting nocturnal. Everyones sodium in our unit is set at 140 for both daily and nocturnal dialysis.

34

Pierre:

Well, for one thing, when you do that in-centre, you’re in-centre. You’re not on your own at home. There is presumably some amount of help available in centre until the ambulance gets there if you crash. Can you imagine what would happen to a person who crashed at home? Remember that a person on nocturnal is not monitored for BP and can’t respond to any potential symptoms of low BP while sleeping. Since it’s not a big deal to scrap a daily treatment for one night (especially if it’s already a hour or two into the treatment), why take any chances? The perspective when doing short daily is a little different, because BP is checked during treatment and the person is awake.

If infusing 200 ml of saline twice doesn’t solve the problem (and this is the same as if you had increased your dry weight by 400 ml prior to the treatment), then you may have a problem. If you just decrease the goal on the machine when your BP is already too low, that is not going to raise BP. On the other hand, saline raises BP pretty quickly.

What are the reasons the bp is low geting on? Can it be ok when you get on and in an hour or two drop too low? If you are asleep, would that stir you and would you have the wherewithal to give yourself saline if that happened?

If you scrap the tx, how much does the neph up your dw the next day?

35

On daily nocturnal, unless a person has heart failure or something, BP can only be too low if DW has become too low over time, or if the person isn’t eating or drinking enough during the day. When I switched to nocturnal, it took a few weeks to get with the program in terms of believing I could eat and drink normally again (including salt - not even a remnant of renal diet). Then you begin regaining weight, and DW will need to go up accordingly. BP is measured before the treatment, and then logged again after going on and finishing taping up, etc. If it’s not too low at that point, it’s not going to be too low during the treatment. Remember that people who don’t have stable BP on dialysis don’t get into the home hemo program to begin with. This is something you just have to have confidence in. BP will go down as you sleep, because you’re sleeping and normal circadian rhythms seem to come back, but it will not be too low if it’s not too low after starting the treatment. Because daily nocturnal restores normal BP somehow, you aren’t constantly yo-yoing between high and low BP as you are on conventional hemo. Keep in mind daily nocturnal is like having normal kidney function 1/3 of every day. Everything you know about not eating or drinking too much goes right out the window!

There’s no need to increase or decrease DW or UF goal unless BP is too high or too low. If I abandoned a treatment because my BP is too low to begin with, my nurse would tell me to increase DW by 500, more or less, depending on how low BP was that night. My neph, on the other hand, has no qualms about increasing my DW as much as necessary. One time, early on, my starting BP was under 120 for a few nights, and she increased my DW by a whopping 1.5 kg at once.

I only mention this stuff because I’ve experienced it. After 25 years of progressive kidney disease and then 2-1/2 years on in-centre hemo, once I started daily nocturnal I quickly gained weight because I was eating better. So, I had a number of DW adjustements early on those first 3-4 months.

Those of us with a lot of experience on conventional hemo tend to go into daily nocturnal with a well-established fear of either being too dry or too full. It takes a while to fully realize that we don’t need that concern anymore.

By the way, I wouldn’t bother to do this 6 nights a week if my results were not spectacular in so many ways… and I’m comparing it to significant amounts of time on in-centre and on short daily.

Pierre

36

Pierre:

BP is measured before the treatment, and then logged again after going on and finishing taping up, etc. If it’s not too low at that point, it’s not going to be too low during the treatment.

But isn’t this what happened to Amba…her bp dropped too low into the tx?

Pierre, when you have had too low a bp going on, did you try giving saline? What effect did it have?

Since you say that adjusting your dw/goal up is not advised for the current tx if bp is too low going on, what changes to make this alright for the next tx?

37

But isn’t this what happened to Amba…her bp dropped too low into the tx?

I can’t speak for others, but for me, this would not have happened unless my dry weight had become way too low over a period of time. But, I have to say that my BP was pretty stable even on in-centre hemo 3 times per week. I do pay attention to any signs of DW gradually becoming too low, and so, hopefully, hypotension won’t happen.

Pierre, when you have had too low a bp going on, did you try giving saline? What effect did it have?

Yes. 200 ml of saline twice will raise my BP say from 110 to 115. I follow the policy that if 400 ml doesn’t do the trick, I’m off.

Since you say that adjusting your dw/goal up is not advised for the current tx if bp is too low going on, what changes to make this alright for the next tx?

I do in fact up my dry weight a bit if my BP is less than 120 before starting the treatment - which means that I’m taking less off. But if BP is much lower than that, it’s already low, and so, the effect of not removing as much fluid isn’t going to help immediately when you’re talking about an 8 hour treatment. It’s only going to help overall over the duration of the treatment - more for the next day than immediately. I don’t know about anyone else, but I don’t do much on my own when it comes to dialysis prescription without consulting my nurse, even if I think I know what to do. They like to be kept in the loop.

Now, little DW changes of 200-300ml aren’t going to be risky for anything, so that I do. There’s a risk to giving yourself too much saline too quickly, but then there’s a limit to what you can do with small amounts. If BP is 105 before even starting a treatment, there’s likely not much you can do about it at that point. It’s too late. So, you skip the treatment, eat more sodium the next day, and get professional advise about increasing your dry weight for the next treatment.

One thing to keep in mind also is that it’s not always necessary to totally skip a treatment. I can easily decide to run for an hour or two instead, just to get some potassium off if I think I should.

38

I have to say I always bristle with always statements. I do not believe there are ever always.

I have low b/p which is again becoming extremely serious. My neph thinks like Pierre, it HAS to be dry weight, well we upped it substantially, to the point where I was puffy and it was immediately noticeable to me and the professionals. However my b/p was 80/60. Xrays don’t show the extra fluid as my heart is good so I don’t end up with any congestion around the heart and lungs, yet I am short of breath. My neph doesn’t believe that fluid won’t show up even though prior to starting dialysis my xray showed no fluid (I made him look it up, so he finally agreed that maybe the xray is meaningless).

My neph appears to not know that there is something called a crit line which will tell him if I am too dry, he also seems unaware that there are medications that will raise my b/p. He flat out told me there was nothing, however, my nurses say there are at least two different medications. My neph says it can’t be related to my moderation pulmonary hypertension (since it is moderate), yet my nurses say my symptoms are completely in line with the problem being pulmonary hypertension.

Please, don’t use terms like always, there are NO always, nephs do NOT always know the machines, nephs do not necessarily know a lot about symptoms that are anormal for dialysis, nephs often have “pat” answers that are not always correct.

Sorry for the rant, but I am so SICK of hearing that my problem is too low a dry weight I can SCREAM.

Cathy
home hemo 9/04

39

Cathy I wonder if you see any impact to your blood pressure when you eat a salty snack? Salt seems to raise my BP. Could you try having a cup of broth in the hour before you get on? Seems like an easy, low cost, low downside thing to try.

40

Cathy, liked your rant although I think it was more about nephs’ lack of dialysis knowledge than about always statements :lol:

41

Sorry, I didn’t mean to make you bristle.

There’s no accounting for special cases. I hope you get it sorted out. You dialyze daily for longer than 2 hours don’t you, as I recall? Maybe it’s just too much dialysis for you if you run it at normal in-centre and short daily speeds. When I went to daily nocturnal from short daily, I really had to let myself eat big time, often more than I was hungry for, and with added salt too, or else my BP was too low. I had to both relearn to eat normally, and gradually increase my dry weight too. I probably mentioned that a few times in my posts of a year ago.

Even I say that people can’t get too much dialysis, but something we often don’t take time to explain is that while it can’t really be too long or too frequent, it can certainly be too aggressive during whatever duration it is. My guess is that some of you who run daily treatments for 3-4 hours have got to be getting almost as much dialysis as daily nocturnal provides, but you’re not really running things as slow and gently as the latter. If that’s the case, you might be experiencing the same thing I did when I started daily nocturnal with regard to blood pressure. Just wild speculation on my part though.

This period a year ago is still vivid in my mind, because for a while there, they thought I might be developing heart failure which in turn was causing low BP. Kind of scary. Luckily, a wopping increase in dry weight solved the problem. I thought my neph was nuts at the time, and I thought I would never be able to breathe, but it all worked out fine.

Pierre

42

Guys, the problem is not WHEN I am on dialysis it is ALL the time. No difference on or off dialysis.

Yes I run for 3 hours and usually 80-87 liters of blood is processed, essentially the same amount as if I am doing nocturnal, but yes, much faster. I’ve tried slower bfr with no improvement. My urea reduction is actually fairly low but my pre BUN is usually in the 40s and post in the 20s. Adjusted for daily dialysis my KT/V is generally around 2, quite good. I have high hemoglobin and hematocrit yet low iron and ferritin. I am NOT a normal patient it seems in any areas, just my luck (trying to smile here).

Some other things that have been tried but without affecting anything is very low fluid removal (by limiting fluids), adding salt to my diet (I do run a low blood sodium of generally 128-132), higher/lower blood flow rates etc.

Again, I wanted simply to point out there there are no “always”, there are definitely usuallys, but never always, except that everyone will always die eventually I guess.

Cathy

43

Here’s a document on hypotension from the Mayo Clinic.
http://www.mayoclinic.com/health/low-blood-pressure/DS00590/DSECTION=1

This page lists possible causes:
http://www.mayoclinic.com/health/low-blood-pressure/DS00590/DSECTION=3

Here’s a page on treatment and lists a drug called midodrine, a drug used to raise BP:
http://www.mayoclinic.com/health/low-blood-pressure/DS00590/DSECTION=7

Here’s a description of midodrine (ProAmatine):
http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/203640.html

Here’s an abstract of an article on the use of midodrine in hemodialysis patients:
http://www.hdcn.com/6/604cnfly.htm

I hope this information will help your doctor discover a way to treat your low blood pressure.

44

I am having a similar problem as you Cathy! I eat salt, I drink around 3L between treatments and it still goes low. Ive put my weight up 1kg last Dx and my BP held up ok. Going on again tonight so see how it goes. Now Im paranoid about heart failure :? This is the 3rd or 4th time this has happened and I have ended up just putting my weight up 1-3kgs and it settles things. Last time it happened I had an echo and all the other tests under the sun and nothing was found to be wrong.