How daily hemo works? It looks that we will begin by daily hemo 4 /week and try 6 times/week.
Please help us with as much info that you can.
Fistula surgery will be scheduled soon.
Have you seen this web site:Kidney School
It is a sister site to Homedialysis.org ; it is the best place to start.
It’s just like conventional dialysis BUT you do it more often for shorter periods than 3x week dialysis…
I do it 6x a week…sometimes 5… for 2.5 hours to 3.5 …they may train you to use buttonhole needle method…which is much better than just using sharp needles all the time…
Thanks, we will be reading the Kidney school.
My husband decided on home hemo ( based on size, etc), and the hospital is offering ( meanwhile) only daily short term. we will see if we can go to nocturnal in time.
There is a difference in the machine from short term daily to nocturnal. I undestand that the flow and pressure are smaller in nocturnal, but can you change these parameters on the “regular” machine?
Thanks for the encouragment, at least we made a decision, now the rest of the journey…
Congratulations on your choice of hemo hemo. No method of dialysis is perfect, and there will probably be days when you will regret your choice. Even PD people have days like that 
I always try to present a balanced view rather than “evangilizing” for any particular method or even any particular machine, however, I do think that overall, daily hemodialysis (5 or 6 days per week) most approximates natural kidney function. PD is done every day, but PD is inherently inefficient. It’s not done every day to better approximate natural kidney function, but rather, it’s done every day because it has to, otherwise it wouldn’t work at all. Of the two methods of daily home hemo, daily nocturnal (also called quotidian nocturnal hemo) by far offers the closest approximation of natural kidney function. In dialysis, there is simply no substitute for both frequency of treatment and duration of treatment. But short daily hemo is quite good also.
Using my program as an example, I trained for 6 weeks. During that time, I did a short daily treatment every weekday, Monday to Friday, and none on weekends. Week 1 I learned how to setup the treatment and put in my needles. From Week 2, I would go in at about 8:30 in the morning and be out by about 1 PM (with time for breakfast in the cafeteria), start setting up, do the actual treatment. Every day, my nurse would make me practice a few emergency drills. Once I was ready to start at home, I first did short daily. In my program, they want patients to gain a bit of experience at home doing short daily before moving on to daily nocturnal. My short daily consisted of 2 hour treatment 6 days per week (to equal 12 hours of treatment per week, which is the standard for short daily hemo).
After, when I moved on to nocturnal, I did 7 hour treatments 6 nights per week. To switch, I had to sleep 3 nights at the hospital with an identical setup as I have at home, where my training nurse made sure I was able to wake up and respond to alarms during the night. Recently, in consultation with my primary care nurse, I started doing it 5 nights per week, still at 7 hours. This seems to be plenty of dialysis, and the extra night off mid-week makes the whole thing a lot more bearable.
Yes, nocturnal requires a few adjustments in dialysis prescription. Generally, dialysate runs at 300 instead of 500, and blood pump runs at maximum 300 (or less) instead of 400. Heparin is given with the machine as an initial bolus and then so much per hour, and it is stopped about an hour before the end of treatment. You cannot do nocturnal hemo with a machine that is not equipped with a heparin pump, without some jury-rigging using a standalone infusion pump. You also usually have to actually add phosphorus to the dialysate (and you can eat all the phosphorus you want in between treatments). Some may need to add som calcium concentrate to their dialysate as well. Other than dialysate and blood pump changes, many if not most on nocturnal hemo set their bicarbonate to 32 instead of the more common 35 or 36. On the more conventional dialysis machines used for nocturnal, almost everything about dialysis prescription is readily adjustable. Once you have learned to run one of these (and contrary to popular misconception, it’s not that difficult), you could practically go into the dialysis centre and run your own treatment if you had to.
Well, it’s about 10pm here, and I’m a little late for tonight’s treatment. So, I had better get on with it…
Pierre
Hopefully your program will be similar to Pierre’s. The difference in not being able to transition to nocurnal as quick maybe that it sounds like you’ll be starting in the home program while Pierre came with an incenter clinical history. You can use the same machine for a range of treatment lengths and frequency. After you settle in ,nocturnal could become an option. If you start with short daily treatments certain settings on the machine will tend to be one way - the blood flow and the dialysate flow. These setting can be changed with the push of a button so to switch from short daily to nocturnal is a snap from the machine point of view.
Blood flow rates and dialysate flow rates gets to how dialysis works (which kidneyschool explains). Inside the artificial kidney there are fine hollow fibers. In the space outside the fibers the dialysate flows in one direction, while inside the fibers blood flows in the opposite direction. The wall of the fibers -the barrier between the blood and the dialysate - is called the semi permeable membrane. It is through this semi permeable membrane that waste and fluid is removed during dialysis.
On the one hand the faster the blood flow and the dialysate flow the more efficient the dialysis. On the other hand the faster the blood flow and the dialysate flow the more stress on the body, specifically the heart. So you and your treatment team have to strike a balance – with short daily they may prescribe higher blood flow and the dialysate flows. I’d say that one of the benefits of nocturnal is you get to run at slower blood flow and dialysate flows
ns
Thanks for your kind words Stephen.
I have no first hand knowledge about the NxStage. Gus is the expert on that one here.
I use a Fresenius 2008K - the same machine used in so many dialysis centres. They call this one the “Baby K” because it’s the same as the standard 2008K except it’s not as tall. When you look at one of these babies already setup, it looks like a big jumble of tubes all over the place. But actually, it’s laid out very logically - easy to understand. It doesn’t even take 5 minutes to install and connect up the tubing. There are really only 2 different tubes - the arterial side, and the venous side, plus there’s the saline administration line, the dialyzer and the drain bag. That’s it. When I set my treatment up, what makes up the hour of setup time is things I have to wait for: 6-8 minutes to test water from carbon filters to make sure there’s no chlorine, 5 minutes to let the water purifier rinse, 8 minutes for the priming cycle, another 7-8 minutes for the machine’s alarm test, and finally, letting the whole thing recirculate for 10 minutes before I can put my needles in and connect. Putting the needles in and connecting takes about 15 minutes altogether (maybe a bit longer if a buttonhole gives you trouble), but you need to do this no matter what machine you use. Obviously, it all gets faster as you get used to it. At first, you’re a little tentative about what you’re doing, and you do everything by checklist. But as time goes by, it becomes second nature.
The NxStage is certainly an interesting concept (and so is Aksys for that matter). It’s transportable, but it does weigh something like 70 lbs, and you do have to bring those big bags of dialysate along or else it’s useless. But hey, if you have the muscle, and you have a vehicle, you can dialyze pretty much anywhere there’s an electrical outlet and a drain. It can’t do nocturnal hemo though. It’s just not designed for it at present.
Short daily vs daily nocturnal is a question people ask me a lot when I participate in support groups. I’ve done both for months at a time. Short daily is the same total number of hours per week as conventional 3 times per week hemo - 12 hours, more or less. With short daily, you’re not getting more dialysis, but you are getting it more frequently. Is it as good as daily nocturnal? Well, no. But it’s much better than 3 times per week. Let’s say you take 2 people who have exactly the same residual kidney function, hypothetically. The person on short daily hemo will have better labs than on conventional hemo, but the person on daily nocturnal will have labs so good that a doctor looking at them would not be able to tell the person has kidney failure - and this is no exaggeration. Look at it this way: short daily treats about 40 litres of blood each treatment (that is, blood actually going through the dialyzer), while nocturnal treats 120 litres of blood per treatment!. So that’s where the difference really is. Now, multiply that by 6 days! I mean, any way you look at it, nocturnal is going to be more like having your own kidneys.
Beyond the labs, there are other differences. With short daily, if you have gained, say, 2 kg (ie. 2 litres) between treatments, you will be taking off those 2 litres plus half a litre for rinseback during the 2 hour treatment, plus whatever you drink during the treatment. So, that means you’re removing at least 1250 ml of fluid each hour. But the guy on nocturnal who has gained the same amount will only be taking off about 312 ml of fluid per hour. That’s a big difference, and it’s a lot easier on the body, and frankly, it “feels” a lot better - almost like not being on dialysis at all. In addition, because there’s plenty of treatment time, the nocturnal guy is only going to be running his dialysate pump at 300 ml/minute and his blood pump at 300 (I usually run mine at 275). Now, that’s going to be a lot easier on the heart over the long term.
Many people with ESRD have trouble sleeping, but this is one of the first things to resolve when you get better dialysis. You just gradually (but fairly quickly) feel more and more normal. Blood pressure normalizes too, especially on nocturnal. I had been on BP meds for like 20 years prior to dialysis, and I continued on them after I started dialysis. During the first 3 months on short daily, I was not able to remain free of BP meds. We tried, but I had to go back on the med after a couple of weeks. You can only go so low with dry weight before you are simply too dry, and at some point, BP just doesn’t respond to lower dry weight. But on nocturnal, totally normal BP - 120/75 - without meds. I haven’t been on BP meds since after the first day I started nocturnal.
So, the answer to your question is that short daily is good, much better than conventional hemo, but not quite as good as nocturnal. However, it’s certainly good enough for most people, and in some ways, it’s more practical than nocturnal. Again, given the same residual kidney function, the person on short daily might still have to take a phosphate-binder, might still have to take a BP med (but not necessarily), and will have to at least keep an eye on daily fluid intake. The person on daily nocturnal can eat and drink normally, without giving it a second thought (except a little to potassium and drink on the off days). Of course, there are always exceptions. Some people on short daily eat whatever they want, but for the reason I already stated, they do have to keep from getting too heavy between treatments.
Yes, you definitely can do this by yourself. I do, every day. I trained without a helper, and I don’t need anybody around at all. I just have to make sure that I have everything I might need during the treatment close by, because once you’re connected, you’re connected - and for nocturnal, that’s 6 to 8 hours. At the dialysis centre, they can disconnect you to go to the washroom if you have to, but at home, most programs don’t want you to do that. Too risky. Once you’re on, you’re on for the duration. So if you forgot to keep the TV remote control within reach, too bad
The other things about doing it alone, or without a trained helper even if you have a spouse at home, is that you shoulder the whole responsibility. If you have a cold or something, you still have to do this yourself. But of course, you can always go in-centre for a few treatments. You remain attached to a specific dialysis centre. You are actually more like a satellite unit off the main centre.
From my participation in support groups (live ones, not just internet), I’ve found that those most interested in home hemo are people on PD, and people with kidney transplants. Knowing that daily home hemo is available is reassuring to them should they need it, because who would want to have to go back to dialyze 3 times per week, with the dietary and fluid restrictions that entails?
I hope you don’t have to switch any time soon, but if you do, daily hemo at home is certainly the way to go.
Pierre
Pierre writes:
After, when I moved on to nocturnal, I did 7 hour treatments 6 nights per week. To switch, I had to sleep 3 nights at the hospital with an identical setup as I have at home, where my training nurse made sure I was able to wake up and respond to alarms during the night. Recently, in consultation with my primary care nurse, I started doing it 5 nights per week, still at 7 hours. This seems to be plenty of dialysis, and the extra night off mid-week makes the whole thing a lot more bearable.
Pierre, if you do 7 hour txs does that mean you must be up by 5 or 6 in the morning? I am wondering if there is any such thing as too much dialysis should one want to do 8 or 9 hr txs in order to get up at about 7-8 a.m.? And do you always get on tx at 10-11p.m. or could you get on later if you desired to?
Pierre writes:
Once I was ready to start at home, I first did short daily. In my program, they want patients to gain a bit of experience at home doing short daily before moving on to daily nocturnal.
Do you think it is absolutely necessary to practice with short daily txs before doing nocturnal txs?
Hi Jane
Hey, anyone else who does nocturnal feel free to jump in here anytime 
if you do 7 hour txs does that mean you must be up by 5 or 6 in the morning? I am wondering if there is any such thing as too much dialysis should one want to do 8 or 9 hr txs in order to get up at about 7-8 a.m.? And do you always get on tx at 10-11p.m. or could you get on later if you desired to?
What time I get up depends on how early or how late I got on. I could easily do 8 hour treatments, but I find I’m ready to get up anyway by about 6. So, I do 7 hours. If I’m on tx at 10, this would mean I’m off at 5 am. Not really a problem for me at all. However, I usually aim to start my actual tx at around 11pm. On occasion, I decide in advance to do an 8 hour treatment. I have that option anytime. I also sometimes decide to get on later, like a couple of nights ago when I wasn’t on until after midnight. It depends on the situation. The flexibility is there if I need it. The longest I can go with my system is 8 hours. More than that and I would run out of dialysate concentrates in the jugs. I could always change to a new jug (it’s not hard), but that would kind of defeat the purpose, since if I’m up to do that, I may as well be taking myself off. Too much dialysis is debatable - after all, our native kidneys worked around the clock. However, longer dialysis might mean more of something has to be added to the dialysate. One thing to make note of is that there is no evidence that longer is better, according to my neph. As long as it’s within that 6 to 8 hours, you’re probably getting as much benefit as you can get. I know that for myself, I get just as good lab results after a 6 hour tx as I do after an 8 hour tx. How long is more a factor of how long you want to sleep.
Do you think it is absolutely necessary to practice with short daily txs before doing nocturnal txs?
No. It’s not necessary technically. I mean, there’s nothing different about it except the need to add phosphorus and maybe calcium to the dialysate jugs. It’s just that (1) they feel people will be more comfortable getting used to dialyzing at home doing short daily when they are awake the whole time, and (2) the whole staff at the home dialysis unit is there and available should there be any problem. After 5pm, there’s only a nurse on call. So, it’s mostly a comfort factor for the new home hemo patient.
Pierre
Pierre, Stephan, Bill,Gus and all of you there!
What a wonderfull think is th internet, we are leraning a lot every posting!
We would have like nocturnal, but our hospital is nor supporting it yet. Bassically they support 3 to 4 times a week, but we will for sure try to get 6 times a week. That will be the first step and then seeing how it goes will try to convince them for nocturnal. It is a question of funding , ie substances, tubing etc. First step is fistula so we are waitng for surgen call, appointment etc.
We will try one step at a time and see what can be done and how my husband will feel.
Again thanks, i try muy work insurance but they do not have dialysis on coverage ( maybe because is covered by OHIP), but will try more.
I am going to finish cooking, here is very very cold but beautiful.
Thanks
nb
“Hey, anyone else who does nocturnal feel free to jump in here anytime”
:lol: Ha ha Pierre, but you are doing such a great job!
Jane,
I went home from training and did not have a good time starting straight into nocturnal. As I have written before, everything for me seemed so much “scarier” to do in the middle of the night as I was also new to dialysis. You may not feel the same as I did. My partner was even more worried than I was ! I would suggest doing at least one or two short runs first (or even more) to get your space, comfort and confidence right.
Unlike Pierre, I do 3 1/2 or 4 runs a week and I only use blood pump speeds on Nocturnal of 225 ml/min for 8 hours and that is what Agar suggests and I like the way he says “good dialysis is like good sex, the longer the better, the slower the better”! :oops:
I usually am on by 9-9.30pm as I feel too tired to concentrate after that (although if we have been out I make exceptions). I then watch TV for a while and sleep for a couple of hours (wake and stretch my arm and hand which cramps ), occasionally have to wake hubby (who is always ready to jump up for fear that something has happened) and get him to move Freni back a bit, so I can get to the toilet (you guys say bathroom I know) while I am still attached ( we now have this down to a fine art) and then it is back to sleep for a few more hours and so it goes until 5am. (We have always been early risers).
I usually have about 2 inches left in my dialysate (part A ) bottle. We have “Bibags” already made up for our bicarb and I use extra big ones for Nocturnal and they look like they could go a lot longer.
The only thing I would say about doing longer runs is the “needle thing”. My arm (and I ) are very happy to have a rest from having those suckers in and if you were thinking of doing 6 nights on Nocturnal you aren’t giving your poor arm much of a rest between sessions. I also find my body (particularly shoulders ) feels stiff and tight from being so immobile for so long. That is why I need to be so active during the day and try and swim or go to the gym as well as walk as much as possible. This also helps me sleep better.
Hope that helps.8)
I’d add the more often the better too.
Absolutely Bill. My apologies. The standard Agar sets as Gold is 48 hours per week. The most I can manage so far is 29. We do what we can. 8)
Beachy writes
so I can get to the toilet (you guys say bathroom I know)
Depends on what part of the country we come from. :roll:
Thanks Pierre and Beachy for sharing your experiences. And Beachy, your posts paint a humorous picture of what partners go through. Partners freak out similar to the way we do, both jumping up in the dark lol! It takes a real game plan for us all to survive dialysis, but it can be done. Thank God for a better tx that helps us regain our lives.
My father is the dialysis patient and I am the (tech?) we trained and then went home and started nocturnal. We didn’t do any short runs at first. Dad adapted right away, I had to put in sometime before I really trusted the machine. I ran dad 9 hrs and it is like someone mentioned it was for the sleep factor. Once dad was on the machine, by the time I got the coffee set up for morning and got myself relaxed it was about an hour before I would actually get to sleep. Because I wanted 8 hrs of sleep I set the machine for 9hrs. Dad was using a catheter and could move about freely so it didn’t bother him. Unlike the others we make our own bicarb so I make enough to last 9 hrs. We have to call in our BP’s etc. to the center by 7am so we can’t really sleep past that. However, if something comes up and you let them know you need to go beyond that point they are flexible enough to let you.
For about the past 6 months I’ve been having dad do 8hrs instead of 9 but it is only because for some reason I don’t feel like I need as much sleep.
It looks like nocturnal is the way to go, but for the time being ( not yet) we will be doing short term daily, this is what our hospital is supporting.
On our visit we have seen the machine, and it looks like yours Pierre, is like the one they use in the clinic , only shorter. The home dialysis nurse showed it to us.
So now we will wait for surgen consultation and then fistula.
Thanks for all the info.
We live in an apartment, how complicated is the water and drain set-up?
It’s actually pretty simple. In my apartment, there is a little storage room between the bathroom and my bedroom. So, because the really noisy component of all this is the little reverse osmosis water purifier (we just call it the R/O), we decided to put mine in the storage room.
All they did was connect and extend a couple of small copper water pipes from the existing pipe that feeds the bathtub, and also a PVC drain pipe, also connected to the drain from the bathtub. All they did to access the existing plumbing is to cut a little square out of the gyprock behind the bathtub, in the storage room (it’s covered over; not left as a gaping hole).
So, in my storage room, I now have two copper pipes, one for cold and one for hot water (the hot water one is actually not used in my system, but they put it in just in case of future need), and the black PVC drain pipe (some people need a kind of valve which mixes hot and cold water, but I don’t). The R/O is in there, but between it and the water supply, there are two little carbon tanks. They look like little oxygen tanks, but they are filled with carbon. Their purpose is to remove chlorine or chloramine from city water, that’s all. The R/O is connected to the dialysis machine via a small, clear rubber-like hose that goes through a little hole in the wall. The dialysis machine drains through a similar hose.
That’s all there is to it.
Pierre
Okay now were just talking about dialysis, right?