1. I sleep wonderfully since I extended my nocturnal treatment from 7 to 8 hours, and at the same time reduced my blood pump speed from 300 to 250 (with my neph’s approval). I can move with almost complete freedom now without ever getting any alarms, even sleeping on the side of my fistula arm (the slower pumping lowers the pressure numbers). It’s truly a revelation, as far as I’m concerned. It has the added advantage that I can put myself on an hour earlier before I get too sleepy, or, if I want, I can get on later but off later as well. It’s really great.

  2. I suspect that most buttonhole problems requiring occasional use of a sharp are caused because we are all taught to remove scabs that are almost inexistant. We go at it too aggressively as a result, and by doing so, we damage the sides of the “hole” and we make the hole larger. What can happen then is that when we try to put the dull needle in, it’s a little bit off the established track (due to the now enlarged entrance hole), and it won’t go in. My solution to that was to stop insisting on removing a scab if there isn’t an obvious one that will come out without digging. If I find there’s really no scab to come out or it’s too deep, I simply make sure I open it up with the tip of the syringe needle. The dull buttonhole needle then goes in, sometimes with a little bit of twirling. I have NEVER had a needle clot, and I haven’t had to use a sharp needle in months (Touch wood!)



Hi Pierre
Glad to hear you are sleeping even better! :twisted:

Tell me, why were you doing 7 instead of 8 anyway?

Another question, you say you use 8 litre bicarb in solution bottles, I think. As it looks like the Aussie days of the nice little BiBags are fast coming to an end after Gambros day in court, how heavy are your bottles and how the heck do you manage to store it all and…how many hours would these bottles last?? (sorry, enough questions) :wink:


Hi beachy

I actually did 6 hours initially when I switched from short daily to nocturnal. Seven hours just seemed to split the difference, and it seemed about right. I didn’t think I would sleep 8 hours, and I wanted to avoid as much waking time on as possible. Unless there’s some medical reason, anything between 6 and 8-9 hours is the patient’s choice here.

My bicarb jugs are 8 litres, so they weigh about 8 kilos. I just have them stacked along a wall along with the acidified jugs. It’s still fewer boxes per month than what the PD people have to store, so it could be worse.

One jug easily lasts over 8 hours. I think it would last 9 hours, but I haven’t tried that myself.



Ta for that.
Silly me, of course they are going to weigh 8 kgs. :oops:


There is no need to teach laddering as well as buttonholes, because when you think about it, they are both the same. When you start out to make buttonholes, you are using sharps, so technically its the same as laddering. You are taught how to find the vein, so if you ever had a problem with a developed buttonhole, you should be confident enough to use a sharp to find another site. Of course if you arent, you ring your HD unit.
I have a few times had to make a new site at home, and it went fine. These sites were usually ones I had previously cannulated, but clotted off after a while. But I at least knew it was ok to needle that spot.

I have never done laddering, except of course when you are developing buttonholes, some site just dont work out.

Pierre…how come you use such a fast pump speed for nocturnal??? Im on 200.


My home dialysis nephrologist says that 300 is the standard speed now for nocturnal dialysis in Canada, but you can go lower if needed. In the early years of nocturnal, they were hesitant to run that fast because they were afraid that long, daily nocturnal treatments would deplete patients of various nutrients. But they have since found that this doesn’t happen. So, they run people faster. That’s the theory as they explained it to me, anyway. Personally, I see zero difference in my blood work results no matter how long I run (6, 7 or 8 hours), or whether I run my blood pump at 250 or 300. I just find that 250 seems right. If it’s faster, I get a kind of pressure or discomfort in my mid-abdominal area.

But as I’ve posted elsewhere, with the longer 8 hour treatments, I find that my problem with restless legs goes away more, and I do seem to have more energy, plus I sleep well.



I always thought that the idea of nocturnal was, that its slow. It seems weird how you could run at 300 for that long. Nocturnal depletes you of vitamins and minerals Im told. I take a couple of supplements to keep that in check. I would be interested to know why they run at such a high speed over there.


300 is not a high speed. 400 would be a high speed.


I guess we are taught differently then. Im not an expert. I didnt often go past 250 as my venous pressures would go to high. I wouldnt go up to 400, I think thats crazy :?


Hi Amba
I’m guessing you are an Aussie? I started on Nocturnal last year using blood pump speeds of 225 as that was Prof Agar’s suggested speed (he said that he chose it is because it is halfway between 200 - 250. This was my personal choice and I have had great results doing 3x 8 hours and 1 x 5 (300ml speed) a week.

Just for an experiment the last couple of weeks I have just been doing every alternate night ( 3and haf nights per week) but speed of 250. Blood tests tonight so will see if results still good. I don’t want to increase my nights if I don’t have too or flow rate as my fistula is relatively young.

Prof Agars website

Question on website explains his reasoning.

You use lower NHHD flow rates than we do – why is this and aren’t high flow rates beneficial and necessary?

Your question says you use a blood flow rate (Qb) of 300 ml/min and dialysate flow rate (Qd) of 500 ml/min. We use an average Qb of 225-250 and a Qd of 300. The following reasons underpin our decision …

Initially in 1993-4, when Uldall and Pierratos began the first NHHD program in Toronto, they used a program of 8 hr dialysis/treatment, 6 x week and a Qd of 100 and Qb of +/- 250.

When I visited in 1999 and decided to ‘import’ his program to Australia, he only recently had increased the Qd from 100 to 200 and finally to 300. We chose to use 300 based on his experience at that time.

Since then, others have used even higher rates - see below - but remember, our two programs (Toronto and Geelong) are based, in the main, on 6 treatments/week whereas many of the more recent ones are alternate nights (7/fortnight or ‘3.5’/week). The less frequent the dialysis, the greater the need to up-regulate flows to compensate for the loss of time and to ensure adequate dialysis.

So, what are the positives and negatives of all this?

Clearly the greater the Qd and the Qb, the more efficient the dialysis … but we already were achieving super-efficient and effective dialysis. Our patients’ Kt/V’s (the current ‘measure’ of dialysis efficiency which, incidentally, I do not believe in for a moment nor agree with at all) were far in excess of those achieved by CHD. Our patients were reaching a glomerular filtration rate (GFR) equivalent of 50 ml/min. 2 normal kidneys produce a GFR equivalent of 100 while CHD produces an equivalent of 13 and chronic kidney disease (CKD) just before entry into a dialysis program is usually equivalent to ~8-10. Compare 8-10, 13, 50 and 100 and you will see that NHD is achieving about 1/2 of normal two-kidney function whereas CHD achieves about 1/8th .

As such we felt no need to ‘push’ the fistula but to simply ‘cruise’ with gentle blood flows and a Qd which didn’t risk either the concentrate or the Bi-bag running out before the planned end of the treatment. The initial rationale for a low Qd was to extend the life of the treatment time and thus ensure bi-bag and concentrate continuity. Remember, our NHHD program is primarily six treatments/week.

As we have introduced patients to alternate night NHHD (7 nights/fortnight or ‘3.5’ nights/week) as well as 6/week NHHD… and here I stress my very strong belief in 3.5/week not 3/week regimes, we have kept our initial Qb and Qd regime for no better reason than it was in our protocol! OK, I know this is not a good scientific reason, but it is truthful! Despite this, we are very happy with our phosphate control, dialysis efficiency and other parameters under both options so I suppose there has been no driving cause to review or change.

As for why higher flow rates are beneficial? … simply, the more ‘passes’ that occur between blood and dialysate, the more efficient is the solute removal. There is therefore some theoretical benefit from both a higher Qd and Qb but if one only - which?

Well, a Qd of 500 compared with a Qd of 300 significantly raises solute removal whereas increasing Qb from, say, 250 to 300 has only a small effect on efficiency - certainly a correspondingly smaller effect than changing Qd. In addition, I have a personal belief (founded more in my experience and ‘gut feelings’ than in my scientific head) that higher AVF flows don’t do the fistula much good. So … if a Qb of 225-250 gives good numbers and outcomes, I think I am justified to be happy with it. In my view then, if one flow rate is to be increased, make it the Qd.


Yep I sure am aussie :slight_smile:

Just wondering what does Qd mean?


Qd =Dialysate flow rate.
My machine is set for Nocturnal at 300ml per hour so my Part A bottle doesn’t run out over 8 +hours. When I do a run less than 5 hours I manually change rate to 500ml per hours. 8)


Is that the fluid flow rate?? I was talking about blood flow rate LOL :wink:


There’s no way a blood pump speed of 300 can be considered fast. Look at in centre hemo where they regularly use 425 or higher for people with a good fistula. Look at your total blood volume for a treatment. If you pump the blood very slowly, like 250 or less, even though you are doing 8 hours, you’re only getting the same amount of dialysis as if you were doing a 6-7 hour treatment. If you are only doing nocturnal 3-4 times per week on top of that, you’re dialyzing significantly less.


Well, it’s considered fast here, Pierre! I know they virtually have to run some in-center patients at higher rates, like 425, just to get the clearances in the pathetically small times allowed. At home haemo, they had 300 as the limit for daytime, they have 250 for nocturnal. I used to run 300-350 on good days, once I was home, but sometimes high pressures would force me to drop to maybe 275. The beauty of home haemo (day or night) is you are getting much more dialysis time, utilising the same consumables (more or less). THe easier you can take it, the better.
Amber can comfortably run on 200, with 300mil fluid rate, as she’s only 1/2 my size!!! :lol: I need the 250 and 500ml My dry weight is currently 128kg Hey! O.K., so I’m a fat bastard :lol: …but when I first came off P.D. I was up to 142kg!!! :shock:


Its considered fast here pierre. Our unit is more about giving adequate dialysis, but at the same time, looking after our hearts. The slower the pump speed, the better it is for you. I do 10 hours at 200 pump speed and 515 fluid flow rate. It is enough to get my bloods very good. Everything is now within the normal range, except the creatinine is still a little high, but its gone from being 1200, down to 140, and Hb is still a bit of a problem, but always has been with me.
I was speaking to one of the nurses and she was telling me how some units go up to 400 blood pump speed, and she was saying its just not really good for you. I cant really remember if she said why.


What are optimal venous and arterial pressures? I run at a blood flow of 450 and dialysate rate averaging just under 12. Tx time 3.5hr. FF now 47. I have to observe VP at 200. I believe 90 to maybe 200bf.
My AP averaged 180’s and VP now 175 - 200. My VP used to be @250 for most of tx. But since I was finally allowed to create a new venous buttonhole it dropped. It is the lowest VP pressure I have had since starting HHD almost a year ago. Like my BUN and creatinine my Vp droppped dramatically (60%).
BUN n Creatnine went down by 60% right after a recent fistulogram and new venous buttonhole. Now from your site am wondering if my blood flow is too high at 450. Nit looking forward to another battle.


I have a bad habit of forcing the dulls now and again if I miss the “tunnel”, usually this is ok as said tunnels are very short. But recently I did cause some trauma at one of the sites so started to make a new tunnel with sharps at a new site.


are you using touch cannualtio?


ok look this up and it will solve your problems with the scrap."kinder gentler methods for scab removal in buttonhole sites Nephrology nursing journal 2011 Sept Oct p439. this is still be used in Australia Canada and the US we are now over 77,000

without a single infection and **they said it could not be done well it has_