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

Discussions for Patients, Family, and Friends HD For Patients
21

We don’t deal with conductivity adjustments on the Fresenius Baby K either. It’s just there, on the display, and you can look at it for fun if you want to - not that it does much :slight_smile:

As I said, it’s just a way the machine uses to ensure nothing is wrong with the dialysate, and if there should be, the conductivity would go outside of limits and trigger a machine alarm so you know.

What machine anyone uses is irrelevant, because whether you have a conductivity display on the screen or not, you still have conductivity. Anytime you have water with electrolytes in it, you’re going to have some conductivity, and the machine may be monitoring it even if there’s no display.

Pierre

22

Oh, after my experience with tx problems that were due to a conductivity that was too low for me, personally, I have to disagree. At least where the PHD is concerned.

The range of an acceptable conductivity level is not very large on the PHD. That range is pre-determined by your prescription of the specific type of bicarb and acid used to make the dialysate. Once the dialysate has been created, mixing both the bicarb and acid with the water, if the resulting conductivity is too low for the prescribed dialysate mixture then the PHD won’t allow a tx.

I wish I still had the piece of paper that detailed the exact contents of each of the different bicarb prescriptions that you could choose from in order to see what exactly the differences were between the first bicarb I was using that resulted in a low 13s conductivity and the current bicarb I am using that is resulting in a low 14s conductvity.

If conductvity did not factor into a person’s tx, then it wouldn’t be on the screen. It’s not there “just to look at for fun if you want to”. Why would they even put it on the screen if that’s all it was?

Conductivity is an important measurement - if it wasn’t, then why would those that mix their own dialysate have to measure it each time to make sure it falls within the acceptable range?

With the SystemOne, I would imagine that their is no mention of the conductivity since the dialysate comes pre-mixed, which means that the conductiviy has alreay been checked. Since their is no outside water effecting the contets of the dialysate, then the conductivity would have no way of changing.

23

E:

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

Yes, much too low, danger zone!!! :evil:

E:

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.

Yes, safe zone :lol:

Solutions must be such that they match the osmolarity of the blood. Low 13’s will be too low for most ppl. One home patient found that she would experience crampiness each time the conductivity was too low on her machine. Her machine tech advised her that changing the amount of water used to form the bicarb slightly would increase the conductivity. This she did and solved the problem.

I began to realize that in-center the conductivity was up and down on machines depending on who mixed the bicarb that day (how much water added). Because again, just a little more or a little less changes the conductivity. I will be running on sodium modeling and all is well as long as the cond. is up. , but should I begin to feel crampy, I can look at my machine and see that cond. is showing down into the mid or lower 13’s. I do not know what is happening with bicarb in this case except that it is the end of the day and maybe it is running low losing its concentration.

Another thing I’ve noticed, if I am switched to different machines in the unit instead of having the same machine each tx, the machine with the too low cond. gives me problems. Whereas my body will release fluid on the higher cond. machine, it will not on the lower one. This is even more intense the closer one is to one’s dry weight.

At home, one can maintain bicarb carefully so cond. comes out at a good level everytime. I have learned with dialysis there is a reason for everything and usually it is just a simple explanation. But because staff and neph don’t know the fine points they attribute it to something else and the real issues are not addressed. This is where being pro-active pays off. Never just blindly follow what is said. Patients must trust their instincts, study, and keep seeking answers until tx problems are solved.

Many, if not most who work in dialysis, including nephs, do not have correct info. on the fine points of the tx… They repeat what they have been told. Only the better educated ones know what they are talking about. Obtaining correct info is a challenge. But just as you saw by adjusting bicarb, everything leveled out. If info is correct it works! It is like anything else in life. One must always be pro-active.

Another important measurement which no one ever mentions is pH. pH should be about 7.3-7.4. Happy to see you applied info. shared and solved your tx problem. You are very welcome…so many have shared their knowledge with me and I pass it on. :smiley: I, too, would have to look to find my old research. I do recall that a neph named Suhail ? covered low cond. in his text and a search at dialysis_support would bring up the info. should you ever need it to show your neph etc.

24

“acceptable range” is a deceptive term, acceptable to whom? The acceptable range of conductivity of dialysate used in-center is 13.5-14.5 Low end cond. may not kill a patient on the spot, but it may do so over time if one has too many txs in a row or off and on where dialysate does not agree with patients’ bodily chemistry. Acceptible range may protect corp from a lawsuit, but any patient who has felt the effects of low cond. knows it is a serious situation.

25

Pierre:

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.

This is another one I have yet to figure out. My bicarb setting in-center was 36 in a previous unit. This caused my CO2 to run low and I had to be on sodium bicarb tablets which greatly upset my stomach. I asked my then neph if the bicarb could be raised, but he said no as it would affect the heart. I don’t recall the whole explanation or if it was even accurate. My current neph has me on a bicarb of 40. My CO2 came right up the first lab and I was able to discontinue the sodium bicarb pills which has made my life much better. Can anyone explain what determines bicarb level?

26

Jane, I’ve encountered those who don’t know, but mostly those who know but pretend not to because they don’t want YOU to know. I was even told by a nurse “you don’t need to know, that is why we’re here” :evil: I guess the attitude is that if you are incenter you are there because you want people to take care of everything, no questions asked. Perhaps when you and I switch to homehemo we’ll be privy to the “secrets” of dialysis lol Lin.

27

I’ll say it again. Conductivity is there on the screen because you need to know what’s going on if you have a problem with your dialysate. Conductivity as such is NOT part of the dialysis prescription. When I set up my machine, I don’t input anything whatsoever regarding conductivity. It’s just a standard setting with a standard width for alarms. When the techs come to do routine maintenance on my machine, they adjust the detector which measures the conductivity so that it’s about 14.0. This is because there’s a 0.5 window on either side of that which is acceptable. Acceptable to who? I don’t know. It’s just an industry standard.

What is part of it though are the K, the bicarb, the sodium. What determines the bicarb for you is very much like determining dry weight. It starts out with the standard amount. But, if your blood happens to not be acidic enough for that, then they can dry a lower number for bicarb (that is, if you are having some symptoms, otherwise, why bother?)It’s NOT the conductivity that determines this, and the small differences in 10th’s that you see from one machine to the next is just the margin of error in how accurately the machine reads conductivity. It’s not the true conductivity. Same dialysate, same conductivity, no matter what machine it’s on. It’s not a true difference, and even if it was, a difference in 10th is not going to affect anything about the treatment. Even the dialysate temperature will affect the conductivity reading, but it’s just the reading, not the true conductivity. At any time, at the best of times, you are not getting a reading of the true conductivity, because there is a margin of error – and you can see that any night if you check it with a standalone conductivity meter. We do this in my program, just to ensure the reading is reasonably accurate. If there’s more than a 0.5 difference between the standalone meter and the machine’s, we can’t dialyze unless we call the nurse.

Pierre

28

Pierre -

For me, it was not just a matter of tenths of a difference in the conductivity of the dialysate that made me have a bad tx - it was a whole number in the difference in the conductivity.

From what I understand about how the conductivity is calculated, it is based on the combination of all the other elements that make up the bicarb. Change the concentration on one or more elements - the result is a change in conductivity. Every patient’s body is different and what one patient’s body can tolerate is different from what another patient’s body can tolerate.

If patient A can tolerate a conductivity of 13.5, then that patient’s body can tolerate the amount of each of the elements that combine to make a conductivity of 13.5. But that doesn’t mean that every patient’s body can tolerate that exact same amount of each of the elements that are combined to make a conductivity of 13.5.

You are right, however, in saying that there is never a “true” measure of conductivity because it is constantly changing. In the PHD, the conductivity is read by two seperate sensors in order to determine what the “real” conductivity is.

But it is not just a number that someone pulled out of a hat. It is not just an “industry standard”. It is a number that has been determined by past patient experiences to find out what typical conductivity works for most patients. Most patients will be find with whatever the conductivity reading is for their txs. However, there are some of us who are more sensitive the conductivity of their txs.

29

I’m not saying conductivity isn’t important and that it can be anything. All I’m saying is it’s not something we can adjust. Once we have our machine setup with whatever system we use for producting dialysate concentrates, we either get conductivity which is within the acceptable range and dialyze, or if it’s out of the range or within the range but too different from what the handheld meter says, we don’t dialyze. There’s nothing I can do to change the conductivity for a treatment. It’s either acceptable or it isn’t. Whatever it is, that’s what it is. Of course, if the true conductivity is way out of what is normal, there can certainly be some serious medical consequences - but the machine would stop and alarm if that were the case, unless it’s malfunctioning (hence the need to compare its reading with the handheld meter). This is why the machine reading and the handheld meter reading must be within 0.5 of each other. In my setup, I have to check this every night.

Now, if you say you had a conductivity of 13 when usually it would be 14, well, then you know you’ve got some kind of problem because that’s already out of range. For me, that would automatically rule out dialyzing that night until a tech gut come to check it out the next morning.

But I’ve never heard of somebody saying “I want my conductivity to be 14.2 tonight, and if it’s 14.0, I’ll change something in my dialysis prescription until the conductivity goes up to 14.2”. This is all I’m saying.

If you go in centre, different machines will vary a little in the meter’s adjustment, the exact concentration in the dialysate jugs depending on the lot (if they use jugs), etc. You also have to check that they did in fact punch in the bicarb your prescription calls for if it’s different than the commonly used one. This is one thing that is easily overlooked, in my experience, and to be honest, some dialysis staff don’t think it’s that important.

Pierre

30

Hey,

I have used both I started with AKSYS and was moved to Nxstage.
I never made every tx with AKSYS. In a month I would have at least
two to three days when I had to go to clinic because my machine was down. The initial cost is also higher for the patient and I think because of the continual running the monthly cost is also higher.
For me there was nothing worse then seeing the dreded AKSYS black screen.
Or failed dialisate problems. For some reason my machine was thought to be a lemon and maybe it was, but so far after 4 months on Nxstage I haven’t missed one tx. I never have to call anyone because I can easily fix any problem I have encountered. This enables me to sleep easy and I think I feel better coming off Nxstage then any other system.
My clinic swithed me because AKSYS didn’t want to service Florida anymore.
There are a few more steps to setting up NxStage but believe me NxStage users I think for me I would stay with NxStage.
Now don’t get me wrong AKSYS would have been great for me if I could be assured I would get every TX but that was my big grip. The other thing was every problem I had they had to fly out a Tech. from who knows were.
Very seldom could I do the service myself. Also the tech would have to be there all day.
I think AKSY’S big plus is it must cost the clinic much less. Just in Dialisate
solution alone makes NxStage more expensive to the clinic and I think that’s why they started me with AKSYS.
I’ll say this If you haven’t used both I don’t see how you can make a choice on the matter.
I guess I bashed AKSYS enough for one day so I’m going to hang my bags tonight and rest easy.

Bruce
NxStage user 3/06 PRESENT
AKSYS 1/06 2/06
3 transplants since 79’

31

Interesting story here, you started just recently and just 2 month you used Aksys? … :o …

P.S. Hey, would you have a picture of you using NxStage at home? Wanna share with us? :smiley:

32

Pierre, you can slightly adjust your conductivity by adjusting the bicarb or sodium. A higher sodium increases your conductivity a higher bicarb decreases it. You are allowed to adjust sodium I think from 138-142 and bicarb from 35 to 40. I ran at a 140 sodium (as my sodium was always low) and a bicarb of 40 as my CO2 was low.

Cathy
home hemo 9/04

33

Hi Cathy

Yes, I can do that too, but my point is that if I do, I’m adjusting those things for what they do, and not conductivity. I think it would be inadvisable to do this just for the purpose of acheiving a specific conductivity, since, if it’s significantly different than what it usually is, there’s probably a technical problem of some kind (maybe minor, but who knows), and it could be dangerous to dialyze. Changing other parameters that affect conductivity could only be masking the problem.

But at any rate, on my machine and in my home hemo program, conductivity is already set to a certain widthh, as I recall, about 13.6 to 14.6. The technicians adjust things so that conductivity falls about in the middle of that range. The only thing we’re concerned about is that it’s within those limits, and that it’s not more than 0.5 off from the standalone meter. BTW, this is exactly the same thing as they do in the dialysis centre. They check the machine’s conductivity reading against a separate meter before every treatment. Otherwise, I could we have confidence that the machine’s meter is correct?

Pierre

Pierre

34

Actually the range is something like 13 to 14.5. I was sick if I ran below 13.5 for whatever reason. I tried to get the tech to adjust it to run higher and the response was that it is safe to run at 13 so no. So I had to adjust it to get it closer to 14. I would have preferred to run at 14+ but could not get it that high. I did have permission to up the sodium and would have loved to run the bicarb lower but couldn’t because of my CO2 levels.

I have heard from many people who feel ill if the conductivity is in the low 13s and my personal theory is that many people who get that weak washed out feeling are running at low conductivity (that was the symptom I got).

Cathy
home hemo 9/04

35

Nope, I checked to make sure, and my machine definitely has the conductivity width set from 13.6 to 14.6. Anything outside of that and it would alarm immediately. I would be prohibited from dialyzing without calling first unless it were a minor problem that I could correct (like a kinked dialyzer line or something).

If dialysate bicarbonate concentration is too low, your blood will be too acidic and you can get metabolic acidosis, and if it’s too high, metabolic alkalosis. I have my doubts that any change in bicarbonate concentration would affect conductivity that much. Since we’re talking about electrical conductivity, what mostly affects this is sodium.

Our safety on the machine is totally dependent upon base conductivity having been adjusted correctly by the technician. Not every machine in the dialysis centre will be adjusted exactly the same though, so I guess that could make a bit of difference in how a person feels if they are sensitive to small changes in blood acidity.

All that being said, I do like to see mine at around 14.0 - 14.2, just because I’m used to seeing there.

Pierre

36

Lin.

Jane, I’ve encountered those who don’t know, but mostly those who know but pretend not to because they don’t want YOU to know. I was even told by a nurse “you don’t need to know, that is why we’re here” I guess the attitude is that if you are incenter you are there because you want people to take care of everything, no questions asked.

Lin, it could be that staff are better educated over there in New Jersey. Depending on unit management, some staff may get more ed. through inservices etc. My current staff is super in that they are very bright/dilligent and want to know accurate dialysis info. I have encountered staff who are as you describe, but usually it is in regard to minor aspects of the tx. The hugh majority of staff I have had are totally blank past the basics of “put em on take em off”. If I was to ask a question such as, “What is conductivity?” they would look at me glassy eyed and say,“Dunno???”

I have tested every staff member I have had thus far to see what they know and 99% are out to lunch on indepth knowledge of the tx and rationales. One RN told me, “This job is very repetitive”. That is what it becomes to them. Few study to increase their knowledge. A tech who has worked for several dialysis units recently told me,"When they hired me, I asked them if they would thoroughly train me on the machine. They said, “Sure, we will give you inservices”. “We haven’t had an inservice yet…still waiting”. This tech is a very concientious person and wanted real ed/training. This tech also said to me,“They only want us to know so much and that’s it”.

When we get into home programs we will go up a level as far as understanding how to set up the machine and putting ourselves though txs unassisted, but indepth knowledge of the tx comes from those who have it and pass it on. Educated, observant patients possess some of that knowledge so I always listen intently to their experience. True dialysis professionals don’t come along everyday. It is not that dialysis is so complicated, rather it’s that the ed./training for dialysis through minimal company classes is too limited. The more knowledgeable professionals are the ones who have studied independently and found the more indepth answers.

Something I would really like to be part of is writing a dialysis curricula for patients and staff that imparts an indepth knowledge of the tx.- something like Kidney School, but going into more depth on how to individualize the tx. As I said previously, accurate tx knowlege is not difficult to learn- it just needs to be compiled and put in one place so everyone can utilize it.

Had quality txs, rather than efficiency and profits, been the goal of corps and nephs for their patients, more would possess this ed/training. Pro-active staff and patients do not accept the staus quo. Staff desire dignity in their chosen profession and patients have lives to preserve.

37

I was once told “you don’t need to know, that’s why we’re here”, and that statement sais it all. If you ask staff if pts. should be educated they will answer “yes”, but if you ask them to qualify that answer they will tell you that pts. should pay attention to their labs and diets, and that is what they mean by education. Once you decide to go on home hemo then someone is willing to train you because at home it’s you, yourself, and you. Of course you can call the nurse or neph. if a real problem persists but in general you must understand and know more than in unit. I’m one of the few pts. in the unit where I go who actually wants to know things. The rest, even the younger more capable pts. could care less. They just want to feel well, and that’s it. Once I was getting ill, three txs. in a row; I had diarrhea and they had to disconnect me. I told them the tmp was going in the pluses (not acceptable for the machine I was on!). I was told it must be the flu, to which I said “no, it’s backfiltration” which at that time was possible with the setup I had. The head nurse asked me what that was, pretending she didn’t know, even said she had never heard of that. A few days later I overheard her talking to another nurse about it and she knew in depth what it was. She looked quite embarassed when she turned around and I was standing right there too. If they think you aren’t educated on something you will be in big trouble. It’s best to learn all that you can; when you go into home hemo I’m sure it will make the training that much easier. I’m sure if they were on the other side they would feel the same way. I’ve had so many nurses tell me that home hemo is better for most pts… I have the greatest respect for those nurses too. Lin.

38

Pierre:

I have my doubts that any change in bicarbonate concentration would affect conductivity that much. Since we’re talking about electrical conductivity, what mostly affects this is sodium.

Hi Pierre,
I would disagree here. My sodium in-center is always set at the same rate ( I double check), but conductivity varies and I would say it is related to the bicarb batch of the day. Also, cond. can vary depending on where a machine is located in the loop. I once had a machine that got a good rate of cond. for months with all good txs until the tech adjusted the inlet valve one day. From then on out the cond. rate was too low. The tech looked all over for the cause and finally determined that that was it. He readjusted the valve and the cond. came back up… smooth txs resumed.

Also, there is an internal setting for cond. that only the machine tech can adjust. If that setting is out of adjustment it affects the rate. So, there are a number of things that can affect cond. Yes, cond. is not a prescription setting, no one is saying that- it is a measurement. Too low a cond. can not just make a patient a little sick, it can make one very ill. And if it is out of range entirely it can cause death. That is why there are different solutions in order to be able to individualize the tx to the patient.

Another thing I learned about cond. once, is eventhough it is normal for there to be some fluctuation in cond., a balanced machine does not fluctuate too widely. By using an external meter on several models, experienced techs found that not all machines were equal in the cond. stability they delivered. Similar to cars, some have finer components then others. We are continually told that all machines are essentially the same. I do not agree. I believe it is definitey true that some models afford more stable cond.

39

True, but it is adjustable. On my 2008k (not at home version, which could be different) there were arrows to the side of that which could be adjusted up and down. Ask the tech next time they are out doing maintenance, they will tell you that according to Fresenius the range is huge.

There are ranges of temperature, bicarb and sodium that are safe to run and that is why they are adjustable. A change in bicarb from 35 to 40 will lower the conductivity .3 if I remember correctly. A change in sodium from 38 to 40 changed it at least as much.

You may be using the at home version of the fresenius so it might not let you adjust these as mine did. But if it does it is easy to see how the change by simply changing them prior to going on treatment just so you can see.

Cathy

40

Lin.,
Oh definitely, there are times staff do know things which they cover up like the backfiltraion situation. They will always protect the unit’s liability and their jobs. This is one of the sadder features of dialysis care- there are few staff a patient can really trust. I have met a few out of the many and they are my heros.

As I said, we will learn more through training for home txs. But even so, it’s just a manual and it does not mean it will provide in-depth dialysis info anymore than the incenter manual techs are trained by provides. Possibly we’ll pick up a few more things, but the real indepth knowledge isn’t found in company manuals. That comes from the experts who study independently. For that we need the better sources.