I would like to thank Prof/Doc John Agar for contributing his two part series on Fluid and Solute Removal. If you haven’t read them, you can find them on the Home Dialysis Home page in the Topic of the Month section. It’s really refreshing to see a professional writing articles that explain complex issues in a way that us common folk can understand. We may not all agree on some of the conclusions, but at least we can be able to discuss them.
Thanks for pointing the article out Rich and thanks, of course to the Prof:0)
I have been pondering this very thing over the last 4 weeks since I broke my dialysis arm and have had to swap Nocturnal for Short daily.
What I have noticed is-
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Because I have to add the 400ml for washback with the Freni, which I don’t on alternate day Nocturnal I still have a UF rate of 600ml every day without limiting my fluids too much. I imagined I would be able to drink more on short daily (doing 3 hours)
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I found if I do SD in the mornings I feel crappish(lethargic) for the rest of the day and tired. So its best to do it at night and sleep it off.
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No cramps on SD, same as Nocturnal. However if I was doing 4 to 5 hours with a 600ml UF I would probably have a cramp and feel less well due to all that extra fluid taken off, as the Prof describes.
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Not as much “bang for your buck” with SD as it is a pain in the butt having to set up a Freni every day, dispose of double the rubbish, deal with extra supplies and have a chunk of your life spent sitting on your backside every day!
5.It is nice to have our bedroom back for ‘normal’ activites though, with SD.
6.However did I whinge about not sleeping on Nocturnal? Can’t wait to get back on that horse again! Bring it on!
Cheers
Mel
Thanks for pointing these articles out Rich.
Did you know I am having a go at blogging? Checkout my blog at billpeckham.com . I think John’s two part article will be good for at least three blog posts.
Hi Folks
Happy New Year To Everyone
Is there a index on this site that give the meaning to things ?
Bill I’ve bookmarked your site. I just was looking at how you sign off
"“T-W-T 25 Liters @ ~400 Qb ~3/3.5 hour per treatment FF35
F-S 30 Liters @ ~250 Qb ~ 7/7.5 hour per treatment FF32"”
The T-W T and F-S I take stand for the nights you do nocturnal 25 and 30 L (volume) @ 400Qb and 250Qb are they rates? I see FF is 35 and 32 If your using nxstage I know them.
[QUOTE=Bill Peckham;15297]Thanks for pointing these articles out Rich.
Did you know I am having a go at blogging? Checkout my blog at billpeckham.com . I think John’s two part article will be good for at least three blog posts.[/QUOTE]
bobobrien
Qb is blood pump speed. When I am doing the longer treatments I slow it down to 250ml/minute; for the shorter treatments I go as fast as my stick will allow, usually around 400 to 450. I like my venous pressure to be less than 220 so that determines Qb.
Oh my gosh, if Bill and Mel didn’t notice the articles, who did? Okay, everybody that reads the articles on Home Dialysis Central raise your hands!!!
Hi Folks
Hey Rich
I did , Is the Prof John ,just Prof or is he a Dr Also? It was Projf John site that and Pierre who posted on his tx set up and just common sense that said noctunal was the way to go, now I will not go to short tx unless something comes that force me . The Prof breaks it down in a way that is very easy to understand.
The thing I don’t understand about thinking here (in USA) is that longer slower just seems to make to make sense. This is why I don’t get the dialysis world here. It is like if a peron needed oxgyen or a heart pace maker etc. The person has the oxgyen and heart machine 24/7 how would it be if any of these folks had to do what we do as in center, how long would there last. How and why did dialysis go from something that a person should have to do tx on a daily need to just three x’s a week for just 4 hrs? Are the medical people who are in charge more into the money thing than the care of a person? This speaks sadly of the medical people who had a chance to set the gudies lines up from the start.
bob obrien
Bob, he’s a real doc.
As to US dialysis, it’s just like the rest of our healthcare system – all screwed up! With most of the centers owned and operated by large for-profit companies, you can say that MONEY comes into play. Just think of it in terms of how many shifts can be fit into a day with 4 hour treatments instead of 8. I’m sure Beth or Bill will be able to elaborate on how all of this started I think when Medicare took responsibility of payment. In the early days there actually was more HHD, but then there was a movement to CHD at in-center facilities.
[QUOTE=bobeleanor;15304]The thing I don’t understand about thinking here (in USA) is that longer slower just seems to make to make sense. This is why I don’t get the dialysis world here. It is like if a peron needed oxgyen or a heart pace maker etc. The person has the oxgyen and heart machine 24/7 how would it be if any of these folks had to do what we do as in center, how long would there last. How and why did dialysis go from something that a person should have to do tx on a daily need to just three x’s a week for just 4 hrs? Are the medical people who are in charge more into the money thing than the care of a person? This speaks sadly of the medical people who had a chance to set the gudies lines up from the start.
bob obrien[/QUOTE]
Hi Bob,
Here’s an article on the history of hemodialysis by Dr. Chris Blagg who is one of the fathers of dialysis.
http://www.multi-med.com/homehemo/blaggarticle/main.html
This article states that in the early days of dialysis, it was done 2-3 times a week. Originally people did dialysis for 10-12 hours. Treatments were cut back to 4-5 hours and eventually to less than 4 (sometimes as little as 2 hours for 3 times a week) once new dialysis machines and high efficiency/high flux dialyzers were made. Then as now, patients’ removal of urea is measured from drawing blood before and after dialysis once a month using a formula to that yields URR (urea reduction ratio) or Kt/V.
Practice guidelines are developed based on published research. The HEMO Study (http://ndt.oxfordjournals.org/cgi/content/full/20/2/278) was conducted on patients who had dialysis 3 times a week for 3 - 4.5 hours. Outcomes were examined to see if there were significant differences. The study authors concluded that longer treatments didn’t yield significantly improved outcomes but it also recommended that Kt/V not be reduced below 1.2. Clinics who believed that URR or Kt/V results indicated that they were providing “adequate” dialysis shortened treatments to three hours or less and added one or more shifts to their clinics, to treat more patients in the same amount of time, and collect more money from payers.
Contrary to what the HEMO Study found, research conducted by dialysis facilities that do short daily or nocturnal dialysis have found improved outcomes with frequent dialysis (daily nocturnal or short-time daily) compared with conventional 3 times weekly dialysis.
Medicare is waiting for results of a government study on outcomes related to more longer or more frequent dialysis before it will pay for more than 3 treatments a week routinely. You can read about the Frequent Hemodialysis Trial which was to start in the fall of 2004. The study was supposed to be completed in 2008. See the following for an explanation of the study.
http://www.niddk.nih.gov/patient/hemodialysis/hemodialysis.htm
It appears the participants in the study haven’t recruited as many patients as needed. If I’m reading the document linked below correctly, another 250 patients are need for the study so the earliest start date to recruit those 250 patients is 2/1/2008 and the earliest end date is 1/31/2010. Obviously this will delay the final report and probably Medicare reimbursement of additional treatments.
http://grants.nih.gov/grants/guide/rfa-files/RFA-DK-07-503.html
HI folks
HI Beth & Dori HAPPY NEW YEARS
I hope the new year is better than the last for everyone.
To get into the study ,any study for that matter will the person need his or her unit to help get them into a study? And what if the persons unit seem not to want get into the study can a person still be in a study?
I read the url’s you added and the last one seem to say that a person had to have the unit help in the study?
Thanks Everyone for a great year
Bob OBrien
In all the years I’ve been on dialysis, none of the 1/2 dozen units I was in ever had patients take part in a study. If it wasn’t for a board like this to light the fire of discussion, there would be even less attention paid to optimum dialysis. It’s hard to believe that at this very moment, dialysis could be so greatly improved for the entire ESRD population if bureaucracy, apathy and greed didn’t stand in the way. Happy New Year to all those who continually work to push the envelope further.
Jane
Bob,
You asked about how people were chosen to participate in The Frequent Hemodialysis Trial. The protocol requires that clinics agree to participate and to follow the study protocol. Multiple clinics work under a few investigators’ oversight. There are certain outcomes that the research is studying. One of the clinics that was going to participate in the FHT in my area dropped out because it couldn’t get a commitment from a local hospital to do the testing that needed to be done as part of the protocol. The reason why the federal government is putting millions into this study is because there has always been a question of whether those that did better on more frequent dialysis would have done better any way because of their characteristics. To address this willing patients were randomly assigned to do conventional dialysis or more frequent dialysis and some were to do these treatments at home while others were do to treatments in-center. The reason they wanted to randomly assign patients was to remove any chance that
Jane,
Dialysis providers sometimes do internal research to examine how well they are doing in helping their patients get adequate dialysis (PD and HD); manage anemia; what percentage of their patients have fistulas, grafts, and catheters; infection rates; blood pressure, etc. as part of improving the quality of care they provide. Some research may focus on helping patients follow their treatment plan or improve their functioning through exercise or goal setting to overcome depression. Generally to get a study published you need to assure that patients aren’t harmed and that their personal information is protected. You can find many small studies of more frequent dialysis at: www.pubmed.gov.
Sometimes individuals or organizations like MEI collaborate with dialysis providers to conduct research with patients who consent to participate. Here’s are some topics that MEI has researched:
http://www.meiresearch.org/pdfs/MEI_CV_9-8-03.pdf
hands up Rich on parts one and two…what the man has to say is too important to ignore
Richard C/O Jessie
[quote=Beth Witten MSW ACSW;15309]Hi Bob,
It appears the participants in the study haven’t recruited as many patients as needed. If I’m reading the document linked below correctly, another 250 patients are need for the study so the earliest start date to recruit those 250 patients is 2/1/2008 and the earliest end date is 1/31/2010. Obviously this will delay the final report and probably Medicare reimbursement of additional treatments.
http://grants.nih.gov/grants/guide/rfa-files/RFA-DK-07-503.html[/quote]
They can’t recruit for the study for the same reason you wouldn’t be able to recruit for a double blind study to demonstrate the effectiveness of parachutes. No one wants to be randomized into the control group. I volunteer for most studies but there is no way I would volunteer for this study if it meant I could be assigned to doing conventional incenter dialysis.
The effectiveness of dialysis itself has never been demonstrated through a double blind study - shall we test what happens when people are randomly assigned to either get dialysis or hospice care? It seems likely that there is a selection bias among those who choose dialysis over hospice care. Maybe that selection bias is why people who choose dialysis do better than people who choose hospice care. We better test this because we wouldn’t want people just willy nilly enjoying the dialysis lifestyle when cheaper hospice care would be adequate.
Webinar Topic.
It has been bantered about to tie our webinar sessions to HDC Topics of the Month. Recently John Agar did a two part series on the removal of solutes and fluids. Part of the article was an overview of how dialysis works and what’s going on in the recesses of the body. After the webinar, additional discussion can be had relating to the topic and perhaps Dr. Agar can continue to participate in the give and take that’s bound to occur.
What do you think?