Specific, step-by-step details of a tx on NextStage & Ak

I have been a PHD user for almost a year now, and I’ve read so many threads on this forum relating to which of the newest DHD system technologies (the SystemOne or the PHD) is the easiest to use. I’ve read several threads like this, but I don’t recall ever reading any post that listed what either of the 2 machines requires for an entire tx (from prepping to actual tx to tearing down), step-by-step.

Now, I am actually very curious to find out how the details of each of the two machines compare to each other.

Since I am a PHD user, I already know, step-by-step, what it takes from start to finish to run a tx using the PHD. But, having never used the SystemOne, I have only a vague idea of all the steps involved.

If other users of either the PHD or the SystemOne would be interested in telling me (and the other readers of this forum) what each step is for running a full tx on their respective machines is, then I would be more than willing to detail my steps for running a PHD tx.

I will give a very brief run down of my PHD tx to start things off.
- Replace the transducer with a new one.
- Cannulate myself and connect to the PHD.
- Run the tx for my allotted about of time.
- Disconnect from the PHD and store the blood tubing set.
- Decannulate myself, hold my sites.
- Replace 2 small bottles on the PHD; 1 bicarb bottle, 1 acid bottle.
- Do a quick check of the chlorine filter.
- The PHD starts its 15-hour “recycle” process.
- Once it’s recyclng process is complete it is ready to be used for
another tx.

That’s a very brief description of the steps I do for each of my daily txs on the PHD.

If anyone else is interested in learning more, or especially in letting us
know each step involved in a SystemOne tx, then please share.

Here is what I do for the NxStage, yes it is more than the PHD, but it also does not take 15 hours for the next treatment, and I can take it with me!!

Turn on machine and heater if you turn them off.
Insert Cartridge, connect arterial pressure port
Insert spike into saline and hang
Push Prime
Insert Dialsate Bag into Heater
Hang Dialysate
Insert spikes and break
Remove excess air from Dialysate Bag in Heater
Done for now, pull tapes, draw heparin, weigh, wash etc.
After a total of about 17 minutes:

Check for excess air in arterial line, put kidney in position and remove any air, and check for any air bubbles in venous line.
Turn off pump and connect saline to saline port, dialysate line to dialysate, and waste to waste (color coded)
Optional (which I do) connect venous and arterial connections using the supplied connection.
Set pump speed, u/f rate, and dialysate rate to prescribed ff
Insert needles, insert heparin, connect and push start

This usually takes about 25 minutes start to finish. I am waiting for approximately 10 minutes doing nothing so I can get a drink, a bite to eat or other things I want for treatment time.

Finished, Turn off machine, remove needles, tape, and that’s it folks. I clean up the next day (which involves throwing everything away).

home hemo 9/04

Those 15 hours is one of the things I like about the PHD. Those 15 hours are not for the machine’s benefit they are for my benefit. In those 15 hours the PHD makes a custom batch of ultra pure bicarb dialysate and prepares a biocompatible blood circuit for my next treatment. From my point of view you are conflating clinical features with convenience features. I have access to the NxStage, I would be happy to use it while traveling but for everyday use I think the PHD offers the best dialysis on the market.

If it was up to me the companies would join together and offer the ultimate package – the PHD for every day use and the NxStage for when the PHD goes down or the dialyzor is traveling.

The goal should be to get more people access to optimal dialysis – high dose dialysis customized to fit your life.

I think both companies, Aksys and NxStage have learned things from each other and the new inclination of future home dialysis machines will sport such features that some of us had icks gripes about.

One example might be Aksys’s new portable dialysis machine, there’s a good reason why they’re headed that way…

My envision for future home dialysis machines is that they miniturize them making life more independent…


I’m on nxstage. Total Time from start to end is 4.5 hrs. ?

Hang 4 Dialysate bags(5000l) 10min
hang saline 30sec
open machine front and turn on both machine and warmer10 sec
get cartridge open put in place close machine connect arterial pressure port and clamp 2min
insert prime spike into saline press add saline.18 min
place dialysate mla bag into warmer
connect mla bag to dialysate bags vent mla bag. 5min?
get kits ready for put on and take off 15min?
hook up and run 2 hrs 55 min avg.
disconnect and rinse back 3 min?
clean up 15 min?

bobeleanor :?:

Cathy (and anyone else )

As a recent convert from your larger Freni type washing machine could you list the advantages over former?
Here in Aussieland I think we still have a while to wait so I would love to have some things to look forward to! As holiday dialysis becomes increasingly difficult out here I would say travel would be the first advantage, but some others?

It will be interesting to see which company breaks into our market first?!.. 8)

Ok, so I envision a machine portable and small enough that we could put it in our purse or breifcase and actually do hd “on the move”. Wheeew, I must’ve been dreaming again lol Seriously though, it’s hard to imagine that technology but think back ten years, and then flash forward to all the technology that has come to pass, and I’m not just talking about dialysis. When consumers (and yes those on dialysis are consumers!) start demanding the technology or at least asking for it companies will deliver because it means profit for them. We are driven by supply, demand, and profit no matter what country we live in. I’m wondering if we start contacting the biggies and giving them our wish list if it will help. Just a thought! Lin.

Think about TV sets in the past 5 years or so. They’ve gone from small enough to just about wear on your wrist to big enough to play a movie on. So, there’s some flexibility in the technology. I’ve heard that flexible laptop screens that you can roll up are in the works. (Cool, hey?)

In terms of dialysis, the need for pumps and motors and alarms has been a limiting factor. There used to be a “Suitcase kidney” in the '70s, I think. I’m not sure what happened to it, or how long it could be used at a time. The good news here is how many different companies are devoting time and energy to finding better solutions. :smiley:

Beachy, thanks for asking.

First let me make it clear that if I could not have my NxStage I would not for a second give up home dialysis with the Freni.

That being said, my NxStage and I are a very happy couple.

My prescription was 4 hours on the Freni. I had to start by 6:30 to be ready for lights off by midnight. On NxStage it takes about 3 hours of treatment. I start by 7:15 and have lights off by 11.

With the Freni I had to spend my one day off doing maintenance, and once a month it took nearly 3-4 hours just to renalin the r/o. NO maintenance on the NxStage.

My numbers are actually better on the NxStage. KT/V of 2+ vs. 1.4. Everything else is pretty much equivalent…

Portability. I’ve already travelled once with the NxStage and have a couple more short trips planned over the summer. Impossible with the Freni. I am also looking into a cruise where I won’t have to pay any extra fees or full cost so the price will be about 1/3 of a dialysis cruise.

It is also a much easier machine to learn. I was setting it up myself the second day (with supervision). My almost 12 year old could understand it from the first day it came home.

I think that is about it, although for me, I feel better on the NxStage and it normalized my b/p and heart rate (or at least got it better, I tend low rather than high).

home hemo 9/04


I think that is about it, although for me, I feel better on the NxStage and it normalized my b/p and heart rate (or at least got it better, I tend low rather than high).

The balance of a machine is very essential. This is why I say that I believe the nephs should understand the machine. The nurses operate the machine or patients at home, but I feel the nephs should understand it so that they can make sure patients get the most individualized txs. It makes quite a difference how a patient feels if the neph understands the nuances of the machine and fine tunes prescription for patients. Anything less = an uncomfotable or barely tolerable tx or less effective one.

It is possible the FR, if tx is prescribed differently and other machine conditions are altered, could provide the balance the NxStage is giving Cathy. But since the NxStage is saving time and can offer travel it is the superior choice.

It seems that most machine techs and nurses also do not understand the nuances of the machines. The aware patients are the ones who notice the difference in how they feel on the various models.

Thanks for those who contributed information in response to my original request for step-by-step information.

One of the issues with the SystemOne that I haven’t really got the sense of after reading several accounts of the setup proccedure, is how exactly the saline is used during a tx?

Is it similar to the in-center machines where the saline is first used to primes all of the lines? Does it use saline to return your blood at the end of the tx? What happens if you need a sudden infusion of saline because your bp is dropping or you are getting some serious cramps from too much fluid being removed?

I am wondering about the SystemOne’s use of saline because the PHD uses ultra-pure dialysate, no saline at all. The lines are actually primed by the PHD drawing your own blood into the lines. Their is a button on the screen that you can push if you need a fluid bolus, and if it is pushed it delivers a pre-determined amound of its ultra-pure dialysate into your blood. When the tx is finished, it returns your blood using its dialysate.

Can someone using the SystemOne explain to me how it utilizes the saline?

Exactly, approximately 500 ccs are used to prime. The rest remains there. It takes me about 250ccs to return my blood. I can use the saline to infuse if needed and if I need too much I can hang another bag, but I’ve never needed to. All blood lines are originally connected to the saline bag for prime. You just disconnect your arterial line and reconnect it to the saline bag and push a button to return the blood. Takes about 5 seconds and about 1 maybe 2 minutes for the blood to be returned.


Here’s how you infuse saline (say, for low BP) on a Fresenius Baby K:

Turn blood pump speed down to 200 (because you never want to put saline into yourself too fast - it can cause heart/breathing discomfort or worse).

Open clamp on the saline administration line.

That’s it. We are instructed to infuse only 200 ml at a time, and so with blood pump set at 200 ml/min, we let the saline flow for exactly one minute.


Gus -

On the PHD, you will always get some dialysate in you, even if you don’t push the “infusion” button to deliver a quick bolus. That’s because the dialysate is what is used to return your blood at the end of a tx. In order to get all of your blood back, some of the dialysate will come along with it (the same way that some saline always gets returned along with your blood on the SystemOne and the in-center machines).

Getting some of the ultra-pure dialysate in me doesn’t feel any different at all compared to getting normal saline in me. In fact, I have heard that for some PHD patients, getting the ultra-pure dialysate actually feels better than getting some normal saline because there is no added sodium with the ultra-pure dialysate like there is with the normal saline.

My neph went to a seminar on the PHD after I had been using it for about a month. When he came back, he was very enthusiastic about the whole technology used in the PHD and felt that it was the best machine he had ever encountered that was used for dialyzing. One of the things he was extremely impressed with was the PHDs use of “ultra-pure dialysate”. He felt that is was much better for a person’s body than normal saline.

He and I did have a little battle in the beginning of my using the PHD, however. As soon as I started training, I would get stomach and bowel cramps about 30 minutes after my tx was finished. I told him this, and he went and talked to some other nephs and everyone agreed that I was simply taking off too much fluid. The symptoms I were presenting were almost the exact same symptoms that other patients who were taking off more than their dry weight called for were experiencing.

So his answer to my problem was for me to raise my dry weight. I knew that my dry weight was not the problem, but to appease him, I increased it by a couple of kg. After increasing my dry weight like he had suggested, I still felt crappy shortly after a tx with the PHD. He told to increase my dry weight some more. That’s where I had to put my foot down and tell him that my problems were definitely not due to having a dry weight that was too low. I was not going to add more fluid to my body when I could tell by the way I felt that I already had too much fluid on me after a tx.

So I did some research, mostly on this board, and found out that there were other patients that had run their tx with a conductivity that didn’t sit well with them, and they would often experience the same bad feelings that I was experiencing after a tx. I showed my research to my neph. He agreed to change my prescription for the bicarb that was used to make my PHD’s dialysate, although I defintely got the feeling that he was making the change just to show me that my conductivity was not the problem.

Well, lo and behold, as soon as my conductivity was raised as a result of the change in bicarb, guess what - I started feeling a whole lot better and never had any crampy, overall bad feelings like I was having when I was running with a lower conductivity.

It just goes to show how right Jane is when she says that the nephs should really understand the nuances of the machines their patients are using.

I guess he had never had a patient’s problems solved by changing the conductivity on the in-center machines before, so he just figured that changing the conductivity on the PHD wouldn’t have any positive effects.

Well, he was wrong in my case. Like I said, as soon as my conductivity was raised by using a different bicarb mixture, my problems went away. I am just glad that I found some information about other patient’s past problems with incorrect conductivity being the source of problems similar to the ones I was having.

Hi estonb!

You have made my day! It’s a funny thing, because I do not have much natural technical abilty, but I am the kind of person who knows how to solve problems and I keep at it until I find my answers.

I learned yrs. ago about the effects of too low a conductivity from a home program friend who was able to speak with some very experienced machine techs and who learned much by trial and error. I have spoken about this simple technical adjustment many times in my posts. I have only encountered a few ppl in all these years who have comprehended the importance of what I was saying eventhough I have shared journal articles and given much info. that clearly speaks to this issue.

I have also said many, many times that it makes no sense for nephs not to have a technical understanding of the machine. Just think how many patients have been unnecessarily hurt tx after tx, because their neph did not know what was causing the problem and had no more of a solution than to go up or down on dry weight?! I have never understood how a neph who is so learned on kidneys could decide that it is ok to be machine illiterate. As a patient, if I was machine illiterate, I would not be able to protect myself on dialysis the way I do. If a tech with a HS ed. can learn to operate the machine, then certainly the patients and nephs can master it -and I don’t just mean the bare minimum. It is not that complicated and with proper training courses all who work in dialysis, plus patients, could achieve a working knowledge of the machine and avoid the many unnecessary problems that occur.

My biggest concern with this issue has always been, that patients can not sustain mulitple problem txs as the effects are so bad it can lead to depression, pain, a reducation in quality of life, humiliation, loss of livlihood, broken marriages, suicide and/or premature death. You would think dialysis management would keenly understand this and train staff accordingly, but they don’t seem to have a clue in all the units I have been in. I have encountered hundred’s of dialysis staff who are inadequately educated and the nephs will put on an act like they know the technical aspects of the machine when they surely don’t!

Anyway, glad you put it together and have a neph who listened and learned and are enjoying smooth txs now. What technical settings/solution values did you end up with?

Jane -

When I started off using the PHD, my bicarb mixture resulted in a dialysate with a conductivity value in the low 13’s.

We were able to find a different bicarb mixture with almost the exact same values in K, Na … things like that, but resulted in a conductivity value in the low 14’s.

That’s all the needed to be changed. Same BFR/DFR, same tx length, same # of txs per week. I just needed to raise my conductivity.

I don’t have my research anymore, but I would bet that some of it came from the posts you put on this forum about the effects that conductivity can have.

I want to thank you for putting that info up on this board. If I never would have found “the answer” to my crappy feeling on the PHD, I seriously doubt that I would have continued using it.

So, Thank You!

I don’t really see conductivity itself as a treatment parameter. Sure, changes you make to the dialysate concentrates may affect the conductivity reading, but the reading itself is just a check that nothing is wrong, such as:

  • no water supply
  • concentrates don’t match what is programmed in the machine
  • no flow out of machine’s drain line
  • dialysate flow has been off too long
  • empty concentrate jug

You don’t change things in order to get a different conductivity. You change things about dialysate for what you need. For example, on a Fresenius, and probably other machines too, you can make changes to sodium and bicarbonate concentrations right on the machine’s dialysate screen, without changing the actual concentrates. On the same screen, you tell the machine what the K concentration is. Sometimes, people feel better if the bicarb concentration is lower. For example, I run my bicarb at 32 mEq/L instead of the more standard 35 or 36. But what the actual conductivity reading is on the machine is pretty much irrelevant, as long as it’s within the alarm limits, and it’s not too far from the conductivity as measured with a standalone meter (which is something I check every treatment). If you do change some things about the dialysate and/or concentrates, you may in fact get a different conductivity, but you don’t shoot for a specific conductivity as a treatment option. This is how I learned it, anyway.

On NxStage,

we don’t have to deal with conductivity settings or such…perhaps the wonders of Lactate dialysate…however, there are about 3 different dialysate concentrations so basicly the right one is given to the patient so still adjustments are done regardless whether its Bicarb or Lactate…