Questions re: cycler programming

Hello, I’ve been doing manual PD for 4 months now. I discovered a hernia, and will be going to surgery soon to get it repaired. I received my cycler and will be starting on it before the surgery. My PET results revealed that I am a slow to average transporter. My kt/v is 3.77 ( I have pretty good residual function left.) GFR about 10. I really only want to be on the cycler for 8 hours. Because of my hernia, I am going to have to do low volume exchanges of 1000ml. My cycler is programmed to have 6 exchanges during that 8hours, so that leaves me with a dwell time of about 1hour 20min. Is that suffiecient for being a slow to average transporter? P.S. My last fill will be 1000ml, but I worried about reabsorbing the fluid if it is left in all day. I seem to be going in and out of having a negative drain volumes. When I first started, my overnight exchange would always be negative. I could absorb anywhere from 100-300 cc of fluid. The same would happen if I left it in too long like past 3.5-4 hours. If I pulled fluid, during the day it was only about 200ml. Then after about a month and a half things seemed to balance out. Now it seems I’m on this negative balance thing again, where I’m always reabsorbing my overnight or long( >4 hours ) fluid.

Glad to know that the plan after your hernia repair is to remain on PD with the cycler on low volumes. You have a lot of residual renal function so that will make it much easier. I presume your nephrologist and PD nurse know about the study published a couple of years ago by H. Shah, M. Chu and J Bargman in the journal Peritoneal Dialysis International (vol 26, p 684, 2006), as they report on 50 PD patients who had hernia’s repaired and remained on PD after surgery. They recommend that patients with a GFR greater than 5 be off PD all together for the first 4 days, then placed on low volumes (such as 1 Liter) on the cycler and always lying down during the cycling so that the abdominal pressure is the lowest with a dry day for 2 weeks. They also recommend a dry day, that is, no last fill for 2 weeks after surgery. The volume can be gradually increased to 1.5 liters in week 2 and then 2 liters in week 3. Sitting is actually the highest pressure, standing next highest, and lying down the lowest. With your GFR of 10, you probably can easily have no last fill and keep your abdomen empty all day. I agree that with your low transport membrane you are likely to absorb any and all fluid left in for the day so it would probably be better to stay “dry” in the day in the 2 weeks after surgery. Since you are a low transporter you would probably do better with fewer than 6 exchanges at night as well. Again, remember that you have a lot of residual kidney function and that will help remove fluid and solutes (creatinine, urea, etc) despite getting just a little dialysis. When you return to full dialysis you can discuss the prescription with your doctor and nurse to be sure you are getting longer dwells at night that match your membrane function. During the day, you may need to drain the last fill at about 3-4 hours of dwell so that you will not reabsorb fluid. With your high overall KtV you could then remain dry the rest of the day. Or you may be able to continue to have no last fill as long as your GFR is 10. You need to be sure to have the GFR measured frequently so that the prescription can be adjusted to compensate when the GFR falls. Hope this helps.

I tried to loggin so that you could get a name, but I haven’t gotton clearance to post yet. (Jaynine1).Thank you for your information. It was actually thanks to this site that I found out that I would still be able to do PD after hernia repair. I printed out all the studies that were referenced on this site and brought them in to my doctor and dialysis nurse because they were ready to put me on hemodialysis. Both my doctor and my nurse said they were familiar with the studies, but my doctor’s complaint was there is no single standardized method of using PD after a herniotomy. After pleading with them and telling them if it doesn’t work out I would just wind up on HD he finally relented and said that I could try the methods that they used in the study. I( I kept pointing to the 2006 study that was the the largest and longest- Shah,Chu, and Bargman.) I did look up the more recent one that you mentioned, but I would be hard pressed to get them to let me go FOUR days without dialysis. My nurse is already nervous about me going 2 days without it. The thing is All my other labs are normal. The only things we had to deal with when I started dialysis was my HGB, which is now where it should be; my PTH which is under control; and my creatinine, which is the one that concerns me that they don’t seem too worried about. My last weeks lab it had increased to 6.6 and I wonder if it was due to a decrease in volume- went down from 1500ml to 1200ml (I can only hold 1500 with CAPD), but I had increased my exchanges from 4 to 5 per day. I sometimes wonder if exchanging every 3-4 hours didn’t allow time for my creatinine to go through. I also recently had to decrease it further to 1000ml due to the hernia. I had just started my cycler this past weekend, and after talking to the nurse manager at the center, I was able to program it to do 1200ml over 8 hours which would allow a little more dwell time, (last fill 1000) and do an exchange or two during the day. So here are some additional questions. 1) How much will my creatinine level rise during those couple of days off dialysis 2) My nurse is going to want me to do twelve hours on the cycler once I get started back on it which is going to be very difficult as I have kids in school. Is that really necessary? I will do it if I have to in order to stay away from HD. 3) In one of the studies it mentioned doing the cylcer dureing the day 3 times a week - how is that possible without being bed ridden all day? My surgery is this Thursday and they will be keeping overnight for observation.

Answer to question #1. Your creatinine will rise when you off dialysis but it should not be of concern. Many people with a GFR of 10ml/minute are not even on dialysis yet so you should be fine for a few days without dialysis. I do not know what symptoms of uremia you had when it was decided that you should begin dialysis, but those symptoms may possibly recur when you are off PD for a few days. If swelling or shortness of breath were among your symptoms before PD, then you should be very careful about fluid and salt intake while off PD. If an elevated potassium was a particular problem before dialysis, then watch your intake of postassium in food very carefully while off dialysis or on a lower PD dose, Your are not likely to be eating your normal diet post operatively, so in all likelyhood that again is not much of a problem after surgery for those first few days. It is more common for dialysis to begin much earlier than 25 years ago so I am not surprised that you began PD at a GFR of 10, but I think this does allow you more flexibility for a special issue like your hernia surgery.
Answer to question #2. It does not seem that you would need 12 hours on the cycler but of course I am not your PD nurse nor your nephrologist. PD is a therapy that requires the patient and the PD team to work together so you need to work this out with them. I think there is ample evidence in the literature and from highly experienced PD nephrologists to use the presciption plans post operatively that I described in my previous answer.
Answer to question #3. I am not familiar with any study using PD 3 times a week. Perhaps it was for home HD which can be 3 times a week during the day. PD is a daily therapy so it recommended that when patients need a temporary reduction in therapy that it can be held for a few days and then be continued each day but at lower volumes and often only at night with a dry day.

We have approved your account; sorry for the delay!

I really didn’t have any clinical symptoms other than extreme tiredness ( I was anemic - HGB in the 9’s) and pitting edema on my calves which I have had for 2yrs now. They didn’t seem to worry too much about it until my creatinine started increasing this year. I would get occasional swelling in my ankles but not like you would normally see in an ESRD patient. No shortness of breath, and my potassium and sodium have always been normal. The only other thing was my PTH as I mentioned before and I am being treated with calcitriol for that. Most of the clinical symptoms they would ask me about, I diidn’t have - food still tasted good to me (smile) No amonia taste in my mouth. Appetite good. They would always say that I didn’t look like my numbers in my labs. (creatinine and GFR- which I think was around 11 or 12 then). I gave them a scare when I went in for a normal Dr.s appt. and my O2 Sats were low 90’s for some reason. (again I felt fine) They did a STAT CHEM and saw my creatinine had risen from something like 4.52 to 5.1. They wanted to put me in the hospital for emergency dialysis then but I refused to go. (My nephrologist was out of town and I felt fine) Then they did a repeat test two days later and it rose to 6.1. I agreed to go but I wanted the on call physician to come by and look at me before they put a central line cath in me. I had absolutely No swelling that day. I had just done a lot of house cleaning the day prior and barely drank water so figured I may have been dehydrated.(I live in AZ) They observed me for the weekend while giving me IV fluids and my creatinine went back down to 4.9. After that episode they rushed to get my PD catheter in place the following friday. I didn’t fight them this time because I definatley did not want to go on hemodialysis (memories from my childhood with my mom). #2 Regarding the 12 hours on the cycler. I think she is trying to shoot for a particular daily volume on the cylcer during the recovery period. That’s the part I don’t get completely. Which is more important: The total volume daily and the number of exchanges it would take to reach that number Or the amount of dwell time that you would need to adequately transport molecules according to your membrane permiability? It just seems to me that if you are a low to average transporter, you would need more dwell time to adequately dialyze. Thank you for your information and thoughts

Jaynine, you and your doctor might find this article by Dr. Joanne Bargman helpful:

The Bargman reference is an excellent summary of what you (and your nephrologist and PD nurse) need to discuss. Remember what she said at the end of the article—that PD is not just to keep you alive but to give you the quality of life you desire. Good luck.

Answer to question #3. I am not familiar with any study using PD 3 times a week. Perhaps it was for home HD which can be 3 times a week during the day. PD is a daily therapy so it recommended that when patients need a temporary reduction in therapy that it can be held for a few days and then be continued each day but at lower volumes and often only at night with a dry day.[/QUOTE]
The study was mentioned on this web site. “Another option is to do an exchange the day of the surgery, no dialysis for 48 hours, then slowly restart PD. In one study, patients did CAPD 3 days a week (10 hours) for 2 weeks, then smaller fills for 2 weeks, and were back to the normal prescription by 4 weeks. On a cycler, exchanges were done 3 days a week for one week, then every other night for 4 weeks. None of the 50 patients had a leak, and none of their hernias came back early due to the PD.” Hernias and peritoneal dialysis: What you need to know.

Here is that abstract–it does not have a lot more info than we put in that article, but perhaps your doctor could get ahold of the full-length article?

EDTNA ERCA J. 2002 Oct-Dec;28(4):173-5.

Continuing CAPD after herniotomy.
Tast C, Kuhlmann U, Stölzing H, Alscher D, Mettang T.

Robert-Bosch-Hospital, Department of Internal Medicine, Division of General Internal Medicine and Nephrology, Stuttgart, Germany.

There is still controversy as to whether PD-treatment can be safely continued after herniotomy (HT). Many nephrologists withhold PD-treatment for several weeks after HT in fear of dialysate leakage and/or hernia recurrence. We report on 12 patients (2 women, 10 men) in whom HT was performed either for umbilical (n = 6), inguinal (n = 6) or open processus vaginalis (n = 3). Surgery was performed according to the Lichtenstein method with insertion of a Marlex-mesh and ligation of the hernia sac. In all patients PD treatment was paused for the day of surgery and 1 to 3 days postoperatively, depending on RRF. Low volume (1.0 to 1.5 l) and high frequency exchanges (6 exchanges per day) were started for several days with a gradual reinstitution of the former PD-regimen within the next 2 to 4 weeks. All patients did well rapidly with no uraemia-or dialysis-related complications. No leakage and no hernia recurrence could be observed 3 months thereafter. None of the patients had to be haemodialysed intercurrently. In conclusion, continuing a modified regimen of PD-treatment after HT seems to be safe and comfortable for the patient.