Hey Gus,
Got any pics of you going to that party! :lol:
Ya, right hereā¦
:roll:
Ha Ha
Why did I know you would be able to come up with something quick as a flash. :lol: :lol:
Hehe,ā¦ 
Seriously, cāmonā¦I mean buttonhole is a GODSEND, isnāt it? Isnāt it a lifesave?..
I been on dialysis in-center many many yearsā¦all sharp needlesā¦first sharp needle stick was at age 12ā¦from there on it was like cutting through your arms splitting it openā¦had several revisionsā¦that stuff is not fun! But hey, now that weāre using buttonhole it should be way way betterā¦similiar to putting earings on or peirced earings?.. :roll:
Wow, interesting story thereā¦the techs couldnāt keep up with you and you just earned your independence from them 8)
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Not only the tech but the nurses and thr doctors to. It took me a while but I pretty much have them all trained to my liking. :twisted:
It has gotten to the point where now the doctors even ask me questions on ocasion about some of the other patients. :lol:
hey gus maybe I can go to that party with you :?: nothing like a good party.
Buttonholes are just the BEST!! No more stress, just 2 neat little ābiteā marks. I havenāt had to use a sharp since I started and I would love not to have to EVER again. Okay, I know it is going to have to happen sooner or later, but that piercing clean skin with a sharp seems so much more of a psychological hurdle than taking off a small scab and going into a ready made tunnel with a blunt. 8)
Itās only been a about three times now with the same spot and last night I could already tell the button whole was starting to take.
I donāt know if any one elseās started that fast but my fistula was ready and working after only two weeks.
My doctors always told me that I heal really fast, so maybe that has some thing to do with it.
Hmmā¦lucky old you, Beachy. I find I have to use a sharp from time-to-time & even still have āfailureā nights - this past Wednesday for e.g. First b/h O.K. 2ndā¦wasted 2 blunts, arm getting sore so used some 'caine, tried a sharp, got a clotā¦anyway I ended up giving up, as by then my arm was so painful there was no way I was gonna be able to sit there, let alone sleep, if I insisted on carrying on. UNfortunately it was my bloods week & I had done the pre- @ QML. So I ended up doing THursday daylight 6.5 hours & my wife took the post- tube up to them for me while I was still on (quick disconnect, sample, re-connect).
And after daylight dx and TWO nights consecutive sleep, I feel great today!! 
Generally tho, buttonholing is great. Better the odd failure than pinsville every sesh, eh? :lol:
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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 nephās 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). Itās truly a revelation, as far as Iām 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. Itās really great.
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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 āholeā and we make the hole larger. What can happen then is that when we try to put the dull needle in, itās a little bit off the established track (due to the now enlarged entrance hole), and it wonāt go in. My solution to that was to stop insisting on removing a scab if there isnāt an obvious one that will come out without digging. If I find thereās really no scab to come out or itās 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 havenāt had to use a sharp needle in months (Touch wood!)
Pierre
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 andā¦how many hours would these bottles last?? (sorry, enough questions) 
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 didnāt think I would sleep 8 hours, and I wanted to avoid as much waking time on as possible. Unless thereās some medical reason, anything between 6 and 8-9 hours is the patientās 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. Itās 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 havenāt tried that myself.
Pierre
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.
Pierreā¦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 doesnāt happen. So, they run people faster. Thatās 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 itās faster, I get a kind of pressure or discomfort in my mid-abdominal area.
But as Iāve 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.
Pierre
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.
Pierre
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
Iām guessing you are an Aussie? I started on Nocturnal last year using blood pump speeds of 225 as that was Prof Agarās 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 donāt want to increase my nights if I donāt have too or flow rate as my fistula is relatively young.
Prof Agars website http://www.nocturnaldialysis.org/faq_pages.htm
Question on website explains his reasoning.
You use lower NHHD flow rates than we do ā why is this and arenāt 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 ā¦
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 āimportā 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 ā3.5ā/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 ā¦ but we already were achieving super-efficient and effective dialysis. Our patientsā Kt/Vās (the current āmeasureā 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 āpushā the fistula but to simply ācruiseā with gentle blood flows and a Qd which didnāt 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 ā3.5ā nights/week) as well as 6/week NHHDā¦ 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? ā¦ simply, the more āpassesā 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 āgut feelingsā than in my scientific head) that higher AVF flows donāt do the fistula much good. So ā¦ 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.