I am having trouble finding a post by Pierre on nocturnal dialysis and fluid gains which I believe I saw yesterday 9/5. Could someone point me to it? Thanks.
I deleted it before there were any replies. I was going to make it shorter, but then I didn’t have time to get back to it. Basically, it just related how the other night I removed the largest amount of fluid I’ve ever had removed since I’ve been on dialysis: 4500 ml. I felt no ill effects either before or after the treatment. No cramps, no nausea… nothing, and no swelling or shortness of breath before the treatment. I always knew that on an 8 hour treatment, I could remove a lot more, since there is so much more time to remove it. 4500ml translates to a UF rate of about 530ml per hour, which is a fairly low UF rate. In a short daily treatment, that would have meant removing over 2000ml per hour.
What has become apparent to me, besides the ability to remove more without feeling ill in any way (my BP didn’t even drop much during the treatment), is that my body seems to tolerate that much fluid gain in the first place. I usually don’t drink that much, but on the occasions that I do, it doesn’t seem to bother me. My BP wasn’t even much higher before the treatment. 4 kg’s worth of extra fluid is a lot for me, because I’m not that big.
I’m not sure what the mechanism is behind all this, but I suspect it has something to do with intracellular vs extracellular fluid and how long, frequent dialysis affects this. It could also be that the extra fluid just isn’t on me that long until the next treatment. All I know is that I regularly weigh-in more than 3kg over my dry weight and I remove it easily.
Pierre
Pierre writes;
What has become apparent to me, besides the ability to remove more without feeling ill in any way (my BP didn’t even drop much during the treatment), is that my body seems to tolerate that much fluid gain in the first place. I usually don’t drink that much, but on the occasions that I do, it doesn’t seem to bother me. My BP wasn’t even much higher before the treatment. 4 kg’s worth of extra fluid is a lot for me, because I’m not that big.
I’m not sure what the mechanism is behind all this, but I suspect it has something to do with intracellular vs extracellular fluid and how long, frequent dialysis affects this. It could also be that the extra fluid just isn’t on me that long until the next treatment. All I know is that I regularly weigh-in more than 3kg over my dry weight and I remove it easily
Was this the case when you were on 3x week in-center dialysis? I mean, could you gain 3-4 before you felt that full feeling and your body felt unwell? Or have you only been able to take in more fluid between txs since being on nocturnal txs? I have not understood how there are no fluid limitations with nocturnal programs. Have never read an explanation of why that is. I understand the part about how there are no hypotensive incidents as the machine has ample time to remove the fluid over 8 hrs. But I don’t understand how the body can hold in excess of 2ks without discomfort and pressure on the heart.
No way! I wasn’t able to tolerate even a 2kg weight gain when I was doing dialysis 3 times per week. 2kg may not seem like much for someone who is 6 ft tall, but I’m only 5’3" and about 125 lbs.
I don’t know where the extra fluid is being held in my body now that I’m on daily nocturnal, but I just don’t feel it. It’s not like there is no fluid limit at all. Rather, it’s that over the course of a normal day of drinking, it would be hard to gain too much before the next treatment without really working at it. Keep in mind that since nocturnal is 8 hours (7 hours for me), by the time I finish a treatment in the morning, I’m only about 17 hours from the next treatment. On regular 3 times per week hemo, you’re looking at about 44 hours from the end of one treatment until the start of the next (and that is repeated all week long). Unless I fluid load early on after a treatment, I’m going to be pretty close to my next treatment by the time I have that extra 3 litres on me.
Pierre
Pierre,
I hope someone can eventually unravel the mystery of where the fluid goes to on nocturnal txs. Eventhough the fluid is coming off daily and there is less time between txs with nocturnal, based on what you said, I wouldn’t get away with feeling bad if I had twice as much fluid intake. Because with in-center txs., I drink little or nothing the evening after my tx. to conserve for the next day. So, I have nearly nothing until breakfast of the next morning. And then the maximum I seem to be able to gain between then and my next tx is 2 or less. But one thing I have observed- the sodium setting of the machine seems to have something to do with how much fluid I can gain. I previously was on a different sodium setting and my average gains were about 1k more. So, I am just guessing that nocturnal txs may allow greater fluid gains due to sodium balance. Also, one time I was critlined and another K came off and I felt so wonderful- my appetite and room for fluid improved. So, it appears the body can hold more fluid if sodium and other conditions are different. The question then becomes, how much fluid intake is wise? Is it based on how the patient feels or on an amount the body can hold without affecting ones heart? The experts have different opinions on this.
Well, certainly sodium will affect it. The more sodium there is in the blood, the more fluid will be there too, as opposed to anywhere else in the body it can be. Fluid and sodium go together. You’re probably right that daily nocturnal, and to a lesser extent, short daily hemo, keep sodium in balance better. By balance, I mean between what’s in the blood and what’s in cells, etc. My dialysis prescription as far as sodium goes is simply straight 140, no profiling (this identical to what I’ve been on since beginning dialysis). So, when I get off treatment, that’s pretty much what my sodium is. Then, during the day, if I don’t eat any sodium, I probably won’t drink enough, and I’ll have to give myself saline at the start of the treatment. I’m guessing that when I come off dialysis in the morning, while the sodium in my blood is about 140, a lot of sodium has been removed from the rest of my body, and so there is a lot of room for sodium (and potassium) to shift from the blood (where it goes initially) into tissues. This probably keeps the sodium in the blood at a more constant level even if I eat a lot of it.
By the way, one effect of daily nocturnal hemo is the better appetite and the ability to satisfy it by eating just about anything within reason. Because of that, my dry weight is already a full 2 kg above what I started with. I went from 56kg to 58kg. Whatever fluid I’m adding now is above and beyond 58kg, not my original 56kg. How do I know that my dry weight is Ok at 58? Well, mainly because my blood pressure has gradually become too low at 56, and the fact that at 58, I show no sign of fluid overload. We’ve gradually increased my dry weight by .2 or .3 kg at a time. The nephs check this by the usual physical examination and also checking the difference between lying down BP and standing BP. Most of the increases in dry weight are simply approved by my nurse based on blood pressure and any symptoms of dehydration I might call her about, and then it’s checked at my monthly or bi-monthly clinic appointments.
All of this is stuff you can only really find out about by trying daily hemo for yourself. I’m just relating what it’s doing for me - and I’m totally outside the ongoing debate between proponents of Aksys and NxStage, since I don’t use either 
I’m very happy with my current set-up, and I wouldn’t change it for anything else that’s on the market at the moment. What seemed a little overwhelming the first week of my training seems so simple now.
Pierre
This is a PS to my last post…
I just want to mention that while I have gained 3-4 kilos once in a while (especially after the day off dialysis), my home dialysis unit does not recommend this - and so it’s not something that I’m advocating on this forum. I’m just using it as an example. They like to see no more than 2 kilos, just in case the patient should have to miss a night’s treatment, for whatever reason. I just wanted to be clear about this.
Pierre
Pierre,
Do you know what your conductivity and pH runs? Are they consistent or do they vary?
Can anyone explain the rationale behind the 2-3Kg fluid restriction?