NxStage System One Enhancements

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

NxStage System One is a special little powerful friendly machine. :lol:

You see, it automatically sets the time you suppose to come off based on you set parameters…for example, if you can handle higher blood pump rates and have little to take off it then you will basicly take you off earlier…so if you say longer is better it is wrong (for short daily). If you ask why, it’s because we’re using Ultra Pure dialysate which doesn’t require us to run longer treatments…

However, if you using standard dialysate you should run longer…

Getting too much dialysis on a dialysis machine is a fact and adjustments are necessary.

Which would you prefer? Suck out all you have and force yourself with supplements and extra food you don’t need?

Or…

Balance and adjust your therapy to a comfortable level?

22

Peirre writes:
In terms of fluid, I have no limits. So far, I’ve found even 4 litres easy to remove on nocturnal. I mean, with 7-8 hours of treatment, you’re still looking at removing less than 600ml per hour. There is a practical limit though. If I end up having to miss a treatment, for whatever reason, and I’m already more than 2 litres overweight, the next day, I have to limit my fluid more. This is because, while the dialysis itself can remove the extra fluid without any problem at all, my body doesn’t really feel well with fluid beyond 2 litres or so over.

Hi Pierre,

I have read several of your posts on fluid and thought I understood you to say that with nocturnal dialysis one can drink more than one can doing 3x week in-center or SDD. But here you are saying that eventhough you were able to pull off 4+, you do not feel well gaining more than 2. Doesn’t this say nocturnal really does not offer no restrictions on fluid? Personally, I have removed a max of 3.5 on regular 3x in-center with no problems whatsoever, but like you it does not mean that I feel well gaining that amount. (Actually my gain was about 3 and the rest was drinks on machine and rinseback).

When I have heard of other patients coming in with huge fluid gains, it has not even computed with me where they put it. Maybe larger people can stuff more in. But does that mean they feel comfortable with it? Based on what a dialysis professional explained to me, the answer is no- no matter who the person, the most the body can hold without affecting the heart is 2-3.

23

I think we’re on pace for this, the first steps of seeing this to work in patients doing homehemo would probably be in external test phases where this tiny nano machine will function right next to the fistula using existing buttonholes…the patient would be able to wear this tiny device strapped like a wristwatch and simply will be used most likely while sleeping. No dialysate will be needed at all… 8)

24

The machines used for nocturnal produce ultrapure dialysate too. Ultimately, it makes no difference to the overall efficiency of dialysis whether the dialysate came delivered to you in a plastic bag or was produced using water from an R/O combined with dialysate components in jugs. The specific dialysis machine is really nothing more than an elaborate support for the dialyzer and the blood and dialysate circuits that feed it - despite all the marketing BS. Everybody who does hemodialysis today uses the best dialyzer available to them, so, the dialyzer is not a limiting factor - at least not the high flux dialyzers of today. Clearly, the limiting factor is our own bodies, that is, how fast you can clear larger molecule items like phosphorus and other proteins. What limits this is how fast these can be pulled out of intra and extracellular space. Short treatments, even though they may be daily, just aren’t long enough for this. This is why nocturnal is superior, no matter what the machine is. Running shorter or longer has nothing to do with the dialysate.

Nocturnal is also superior, at least theoretically, because with the long, slow treatments, your never really pulling enough fluid off per hour that it will stress the heart. I mean, as I’ve mentioned before, it would be rare to have to take off more than 500ml per hour. The vast majority of the time, it’s barely over 300 ml/h, even with what would for be a large weight gain using short daily.

I really don’t know how anyone can argue that short daily treatments are better able to balance and adjust therapy to a comfortable level. It’s just doesn’t make any sense.

There is also no way that a person on any form of dialysis would have to eat more on purpose than their body can handle. It’s just not like that being on dialysis. Even the best dialysis available today is not going to be the same as well-functioning native kidneys, so in that sense, I agree with those who say that you simply cannot get “too much dialysis”.

Hi Jane

What I keep stressing is that there is no limit in practical terms, but some people may not be able to handle as much fluid intake than others. For me, personally, daily nocturnal means that I don’t have to closely monitor everything I drink. I can just keep mental tabs on it, and unless I eat a very high sodium diet that day, I’m not going to need to drink more than 2 litres to quench my thirst. If I go over, no problem. It’s not going to be on me for long, unless my machine conks out and I miss the next treatment, and it’s not going to be a problem taking it off at all. People can easily handle more fluid in the short term. It’s having the extra fluid on most of the time which is the killer for the heart.

Now, on regular in-centre hemo, you can gain 2 litres without problem, maybe 3, but remember, that’s for two days, not just one. Being able to drink to litres per day is a lot more satisfying than being able to drink 2 litres per two days.

But in the end, all that really matters to me, other than to be able to eat and drink normally, is how I feel. I can get out and walk immediately after dialysis, and I can exercise now to a level I couldn’t even approach on either conventional or short daily hemodialysis (it was a little better on short daily, but no match for daily nocturnal). To me, that’s the biggest test.

Pierre

25

The quality of the dialysate is a big factor on the outcomes of the treatments we recieve. The dialyzer is also another thing…when it comes to re-use and using standard dialysate then the machine requires higher blood pump speeds and higher dialysate volume speeds to compensate the short 3 hours treatments…

Some home patients like myself are fortunate to have ultra-pure dialysate which only requires to pass one time through the dialyzer. Even better, the new updated dialyzer NxStage is supplying for it’s patients makes clearances of smaller and middle molecules much better. Will they stop there? I think not, they will make even better and too good to be true until one tries it.

Daily-Short for most of us is the best option you can get…based on my own experiences…just like the patients of nocturnal say they eat more, drink more, and don’t take medications…same here. I don’t take prescribed medications as when I was in 3x… Renegel? Hahaha, thing of the past…intervenous iron? hahaha, thing of the past…blood pressure medicine? hahah, thing of the past…

But again, the quality of the dialysate and dialyzer matters…it’s a fact…

26

I don’t know what you mean by dialysate going through the dialyzer in one-pass, but I can assure you mine only goes through once, and I can almost assure you it’s no less pure than yours. There is no backflowing needed with the machines used for nocturnal. The only difference is that yours comes pre-mixed in a bag (some other kind of machine has been used to produce it in advance), and the only purpose of that is to eliminate the need for connecting the machine to a water source (which I’ll concede is an advantage in terms of portability). It’s also an acetate-based dialysate rather than bicarbonate, but that’s another discussion entirely.

The advantages of long, daily nocturnal hemo are so great that it almost seems silly to even argue about it. Almost nobody ever switches back. But as I’ve always said, there are some disadvantages too. One is that if you’re sleeping through it, you can’t monitor it and you have to trust the safeguards on the machine.

I’m not saying anyone on short daily has to switch. We all decide what is good for us and what tradeoffs we are willing to make for what we want. Plus, not all options are available in all locations.

Pierre

27

No, it’s not acetate, it’s Lactate based…

Anyhow, I think the issue most likely should be…“Should InCenter Require to use Ultra-Pure” and stop re-use…

Some nice research readings…

http://jasn.asnjournals.org/cgi/content/full/13/suppl_1/S78

Interesting small research about Lactate/Bicarbonate

(Due to small patient numbers these comparisons did not achieve statistical significance.)

P.S. Of course every method has its bads and goods but nothing compares a portable 50lb machine in the back of a convertible red corvette heading towards the horizon… 8) Can’t wait for something smaller…

28

Pierre and Gus,

What blood flow do run at ?

Gus, what do you view as the cause of your iron stability, have you also stopped epogen?

Also…
Gus Wrote:

Interesting small research about Lactate/Bicarbonate
Continuous veno–venous haemodialysis with a novel bicarbonate dialysis solution: prospective cross-over comparison with a lactate buffered solution | Nephrology Dialysis Transplantation | Oxford Academic
(Due to small patient numbers these comparisons did not achieve statistical significance.)

from your linked article…last paragraph…
“Patients who had elevations of lactate during lactate dialysis had a high mortality (6 of 7). These patients had an even greater disparity in lactate levels (4.3±1.4 vs 1.3±0.3) and blood pressure (68.0±7.7 vs 87.2±17.1) between lactate and bicarbonate dialysis. Due to small patient numbers these comparisons did not achieve statistical significance.”

Now, Gus, I am not the sharpest knife in the tool box, but it looks like the reason that they had small patient numbers, is because they were killing the ones on Lactate dialysis ! Please, to offer another interpretation.
Guillaume

29

Pierre,

Rereading your lengthy post above ;-), I see where you have stated your pump speed of bet. 200-300, the reason I asked is that for years I resigned myself to the fact that I was going to live with high blood pressure because I refused to take BP meds and I just accepted whatever that was doing to my heart and circulatory system. Then in 1999 I had some interactions with Zyblut Twardowski (y?)M.D. P.H.alphabet soup… who had about 200 or so home hemo patients in Missouri. he helped bring the Aksys machine into being, he used to be on the board but isn’t anymore, don’t know what happened to him.
He theorized that the reason for high blood pressure in dialysis patients was an aclimatizing of the patients circulatory system to the high blood flows during 3x in center dialysis. The flows I was running at the time rountinely were 400-440. He told me he had great success with his patients running a maximum of 300-350 blood flows …they were getting off there BP meds and having NORMAL BPs. I followed his advice and have had normal BPs sans medication ever since. Average is 107/60-65.
Occasional high sodium(lots) is all that I noticed will effect it. It does not persist.

The one thing that has kept me from Nocturnal … I lived in Roanoke, VA near the Lynchburg dialysis facility that did the Fresenius nocturnal trials and I considered joining the trials about 5 years ago… was that for many reasons that I will not go into…(belief system stuff) DEEP SLEEP is a very important comodity to me. And I could not be assured by the team of getting that on nocturnal… it was the only major stumbling block and I was not willing to forgo that even for a trial. I realize people sleep on nocturnal, the issue for me is what level of sleep, what level of rest, what reprucussions to ‘consciousness’ may occur over short or long term deprivation of deep sleep.

Regards,
Guillaume

30

Guillaume writes:
Rereading your lengthy post above , I see where you have stated your pump speed of bet. 200-300, the reason I asked is that for years I resigned myself to the fact that I was going to live with high blood pressure because I refused to take BP meds and I just accepted whatever that was doing to my heart and circulatory system. Then in 1999 I had some interactions with Zyblut Twardowski (y?)M.D. P.H.alphabet soup… who had about 200 or so home hemo patients in Missouri. he helped bring the Aksys machine into being, he used to be on the board but isn’t anymore, don’t know what happened to him.
He theorized that the reason for high blood pressure in dialysis patients was an aclimatizing of the patients circulatory system to the high blood flows during 3x in center dialysis. The flows I was running at the time rountinely were 400-440. He told me he had great success with his patients running a maximum of 300-350 blood flows …they were getting off there BP meds and having NORMAL BPs. I followed his advice and have had normal BPs sans medication ever since. Average is 107/60-65.
Occasional high sodium(lots) is all that I noticed will effect it. It does not persist.

What is your Kt/v? I have always chosen to run at a lower blood bump speed based on advice I received early on that a fistula should not be run too fast. My first doctor had me on bp meds which made me feel awful. A subsequent doctor decided I didn’t need the bp meds and admitted to me that I could of been taken off them much sooner. I felt much better as soon as I no longer had to take them. My clearance has always been very good to the surprise of doctors who thought I could not get a good clearance with a low blood pump speed. My bp is not low like yours, however. I come into dialysis at about 135-150. I quickly come down as soon as the fluid is removed.

31

Hi Guillaume, Gus, Jane

I think the one constant about all this kidney stuff is that everyone is different. Blood pressure is a good example. The improvement I’ve had after starting daily hemo is dramatic for me, but, I’m someone who for years would be lucky to get 150/100 on 4 meds. Just to set the stage, I was hospitalized twice for malignant hypertension higher than 220/120. The kidney disease I had is notorious for that. It seems to damage the kidney’s filtering ability without impairing its ability to raise BP (in some people, anyway). In the 5-6 years before dialysis, I twice wore a 24 hour BP monitor and both times, separated by 2-3 years, I averaged 170/110 over the course of 24 hours. When I started dialysis, I finally started getting some better BP readings, but with meds. I would go into dialysis about 160/100. I never had hypotensive episodes on regular hemo, not even once.

Just one week after starting short daily hemo, my pre-dialysis BP was more in the area of 140/90, and sometimes lower. Post-dialysis, I almost always had rebound hypertension in the area of 155/100. We tried stopping the one med I was on at the time, but my BP gradually went up, and I had to start Adalat XL. In short daily, we were running the blood pump at 400 (about the same as when I was on conventional hemo). My neph (who has a lot of experience with nocturnal) insisted that my BP would drop once I switched to nocturnal, and that’s exactly what happened - and it only took a week or two to become consistent. After a couple of months, we had to raise my dry weight by 2 kg. Now, even with a 3 litre fluid gain pre-treatment, I almost always come in lower than 120/70. It stays relatively stable during the treatment (blood pump 300, dialysate 300). and by morning when I come off, it’s in the neighbourhood of 115/65. Now, all this might not mean as much to anyone else, but for me, this is more than dramatic… it’s spectacular. I’ve had plenty of problems with BP meds over the years, so, just having normal BP without meds is more than worth the effort and inconveniences of daily nocturnal. Note that my program leaves it up to the patient as to whether they do short daily or nocturnal, so I could decide to switch to short daily anytime if I wanted to.

The idea of blood pump speed is interesting one though. I don’t think that’s the factor in my case - but who knows?

Re: deep sleep

That’s something I’ve though of. I thought myself that it might be a problem, but so far, it doesn’t seem to be. When I get up in the morning, I actually feel refreshed and ready to go. I even seem to need less catch up sleep during the daytime than I did before - virtually none, in fact. I don’t know what the consequences might be in the long term, but since I started nocturnal, I feel so much better that I couldn’t even imagine going back. I have energy like I haven’t had in years.

Look, I’m not trying to convince anybody. I’m just reporting on my own, personal experience, for anyone who might be interesting in hearing about it. As I said, in my home dialysis program, short daily and nocturnal are interchangeable, so, it’s not like I’m permanently committed to daily nocturnal. In Canada, there are no financial incentives for nephs to put patients on any particular kind of dialysis. But based on my experience with it so far, there is just no way I would go back to anything else unless I was forced to. I only post about here because there doesn’t seem to be much interest from anyone else about daily nocturnal.

Honestly, I don’t know what my Kt/V is lately on nocturnal. It hasn’t been included in the format of lab report I get a copy of. I’ll try to find out though. I’ve just been assuming it’s Ok, since I get over 120 litres of treated blood volume every night. My neph only wants to see me every two months at this point.

For Jane…

When I say I start feeling uncomfortable when I get up higher than 2 kilos over my dry weight, I just mean that I start feeling a little bloated in the abdomen. It’s not like I can’t handle it until the next treatment. I don’t get short of breath, and I don’t even have any ankle swelling. I’ve had to miss one treatment when I happened to be 2.5 kilos overweight for a technical problem, and I made it fine another 24 hours until my next treatment.

For Gus

I actually don’t take any supplements, except the same renal vitamin I’ve been on since before I started dialysis. I add calcium and phosphorus to my dialysate jugs, but that’s only because these are designed for conventional hemo. They don’t make any with the right amount of these things in it for nocturnal patients. Other than that, I get Venofer once a month, 2000 units of Eprex weekly (may soon be reduced though). The only additional med I’ve started since nocturnal is calcitriol.

Pierre

32

Just my fathers experience in contradiction to what Gus said about everything being sucked out of you. Dad is 81 and a small man. I am sure he doesn’t eat close to the amount younger patients do. He has been on nocturnal 5 years and is not pumped full of supplements. He also felt great on nocturnal and sleep well. I am considering the switch of nocturnal to daily but I wouldn’t want to run any less than 4hrs daily because I would definitely keep the slow pump speed. I do believe it is easier on the body. The reason I am considering the switch is to keep the amount of heparin per treatment down.
To make things easier on dad I would run 8:30 to 12:30 so he could sleep during dialysis.

33


Assumptions are bad, but you can suspect that, but we don’t know the actual truth of the latest research. There’ many unanswered questions in that small research study…just like they said…“Due to small patient numbers these comparisons did not achieve statistical significance.” A thorough investigation is required…

Wouldn’t we be dumbfounded if the latest research showed the opposite? Time will tell…

34

Pierre wrote:

My neph only wants to see me every two months at this point.

That’s very interesting, my Nephrologist says(and I assume that all these nephrologists are operating under the same Medicare payments and guidelines) that she cannot get paid by Medicare unless I see her every(damn) month. Could there be any MSWs lurking (lurk,lurk)out there who could clarify this for me. What are the new rules for mothly physician visits for dialysis patients? Did it change in January? What’s the deal…is there any physician discretion?

you know I dialyzed for 6 months without a physician, with my own (owned) machine and a large back-up of supplies(they cut my deliveries)
If I could I would do without one now. But in the U.S. they will not allow you to self-manage (my definition of self-manage)

35

Gus Wrote:

Assumptions are bad, but you can suspect that, but we don’t know the actual truth of the latest research. There’ many unanswered questions in that small research study…just like they said…“Due to small patient numbers these comparisons did not achieve statistical significance.” A thorough investigation is required…

Wouldn’t we be dumbfounded if the latest research showed the opposite? Time will tell…

Yeah Gus…I don’t want to assume :roll: …it says THEY DIED whatever I assume, it says that the “elevations of lactate during lactate dialysis had a high mortality (6 of 7)” Those with High Lactate on lactate dialysis died, more than 6 of the 7 patients…more than 90% mortality …hard to get folks to volunteer for that study at least for the Lactate dialysate side.
That should create a few phone calls for clarification…

36

Jane
I have labs this week …I’ll let you know …haven’t been paying much attention to the Kt/v …get back to you

37

There’s a hint there, but no sufficient evidence…high lactate in those patients merely shows that these patients must have had liver failure or disease which lactate based dialysis wasn’t compatible with them…so in other words, if you have liver troubles then lactate based dialysate is not for you. If you look at PD patients, most of them use lactate based solution…

38

Gus wrote:

There’s a hint there, but no sufficient evidence…high lactate in those patients merely shows that these patients must have had liver failure or disease which lactate based dialysis wasn’t compatible with them…so in other words, if you have liver troubles then lactate based dialysate is not for you. If you look at PD patients, most of them use lactate based solution…

As you know, doc, there are many, and varied causes of lactic acidosis only one of which is liver failure. Many chronically ill patients even with normal liver function have increased lactate levels.
And there is NO indication they died from Liver failure.

Verily… Let us Assume not lest we be made into an ass-umptions. :!:

39

Then that puts us us in the same position… :oops:

No sufficient evidence, it an unfulfilled research which wasn’t taken into full consideration. I wouldn’t worry about it as current data is way ahead… and niether of those patients in that study DIED… :roll: