Switching from Aksys to NxStage

This year has been a challenge so far dialysis-wise. Switching machines was on top of feeling sick (cold & eye infection), taking more than the usual number of dialysis days off - some operator errors, some just needing a bit of a break - plus trying to meet commitments at work and at my other job as an NKC volunteer. Next week I am having the first revision to my nearly 17 year old fistula. Today I am home instead of with my brother in Vegas – the first time I’ve canceled a trip due to dialysis related reasons in the entire time I’ve been dialyzing. I didn’t want to be under dialyzed before the surgery and I had not planned on taking a cycler.

So this has been a difficult period without regard to which machine I am using but after four treatments on the System One/PureFlow combo I do have some initial impressions. It will require more time to use the System One but clinically it feels like I am getting enough dialysis. It is possible that I will try nocturnal or a mix of nocturnal and shorter daytime treatments but for now I am hoping my boss willl let me work from home for four hours a day. I should be able to cover my job and dialyze and that would net me more free time. I’ll see this week what my options are.

Good luck Bill. I hope things work out well. 4 hours is a lot. What do you do? Hopefully you can do computer work, telephone work, etc. With 30 minutes between vitals checks, it allows for quite a bit of time.

Bill,

I sure do understand whats it’s like to have things go topsy turvy read my post under Fresenius to NxStage. The only thing I can say is knowing you and knowing me we will at some point again be able to make the best of it all.
Whatever it takes.

Good Luck
Marty

Bill,
Good luck with work. Do think about nocturnal. It really does make a difference. You will be dialysed so much you will feel like a whole new person.
I know Ralph keeps saying how much better he feels. People meets us and can not believe he is on dialysis.
You are such an inspiration!
Pat

Let me know how working 4 hours while undergoing treatment consistently works for you. Some days I can get work done, while others I’m pretty tired and can’t focus all that well. I wouldn’t be ablt to commit to 20 hours of consistent work a week while dialyzing. It may just be that fathering a seven year old and a three year old is all the mental and physical stress I can take for now.

Let us know. Good luck. Erich

So, Bill, why are you switching and how long have you been using the NxStage…and what are your ‘other’ imressions…seems like there would be a lot more to say and you usually have no problem communicating. :wink:

I have done the same switch and would like to know.

A Traveler

Aksys announced in mid-January that they’d be declaring bankruptcy this month, all PHDs had to be pulled from service by January 31. They came for my PHD on Tuesday 1/30; my last PHD run was Monday night. I think I started using the PHD August 22, 2002 so I had a 4 year and 5 month stretch receiving I think the best dialysis minute for minute that I’ve had in 16+ years as a dialyzor.

As far as my impressions I’ll put aside the obvious - portability, support model (NxStage) biocompatibility, F80 kidney (Aksys) and most importantly the System One is available, the PHD is not - and talk about the central question: dialysate flow rates (Qd). The NxStage System One turns conventional wisdom on its head; I am trying to understand, trying to revisit my assumptions and identify any baseless biases, as always I reserve the right to be wrong and change my mind. I offer my impression as an individual who has experienced a wide range of hemodialysis modalities and as one who tries to understand the choices we dialyzors face and also understand the choices faced by the dialysis manufacturers and providers. So while I write of the differences between the PHD and System One, really it’s their approach to the choices that resulted in two very different machines, it’s that approach that I’m comparing.

Dialysate is at the center of this, a limited quantity of dialysate is what both machines have in common and how they employ this limited quantity of dialysate is what differentiates them. Some background: both machines use ultrapure dialysate which apparently can not be delivered on demand. Dialysate is delivered on demand by a standard dialysate delivery system. While a standard home dialysate delivery system (RO, carbon tanks, acid & bicarb jugs) meets all current purity standards, ultrapure dialysate has shown clnical benefits so both companies made the choice to use ultrapure dialysate. The PHD makes 50 L of ultrapure dialysate each night, and uses 50 L each treatment. The System One with the PureFlow makes 60 L of dialysate at a time and uses 20 to 60 L each treatment (there are bags but day to day I’m using the PureFlow).

The PHD squeezes the maximum dialysis value out each unit of dialysate by multi-passing i.e. running its 50 L of dialysate through the artificial kidney about once every 62 minutes (Qd=800). There are studies that show the advantage of Qd twice blood flow (Qb). My understanding (as a journeyman in the Carpenters Union) is that in an artificial kidney when blood & dialysate are traveling in opposition on either side the permeable membrane at this ratio: Qd >= 2 x Qb, a sort of “molecular magic” happens along the membrane – shear. This shear makes solute transport more efficient – more dialysis. The PHD also increased solute transport by artificially increasing the UFR by .8 L/hour which triggered convection when the gross UFR was greater than 1 L/hour.

The System One squeezes the maximum dialysis value out each unit of dialysate by slowing down i.e. running its 20 to 60 L at Qd less than Qb. The System One is new; I haven’t seen peer reviewed data on this approach but I can repeat what I’ve heard. The System One works by increasing the “dwell time”. By using slow dialysate speeds the dialysate spends more time along the membrane saturating it so that a different “molecular magic” happens – call it saturation transport. Ones peritoneal dialysis dose is a function of dialysate quantity and dwell time, the System One uses the same language. The idea is that by slowing the dialysate down – slower is better – the dialysate has more time for solute transport.

The System One does work. However, against the proven efficacy of the F80 combined with Qd = 2 x Qb it is not clear if I am gaining anything clinically for the extra time I am compelled to invest. So I guess there are two questions: am I getting the most out of my time on the System One (less dialysate/lower FF or slower Qb/higher FF)? And how much time (dialysate) do I need to use? It would be nice to get back to a 170 minute run which was my PHD standard but that is not the main goal. I understand the many ways to shorten ones treatment time on the System One but they all involve subtle changes to dose. What I want to know is what I would have to do at a minimum to have as good a clinical outcome on the System One as I experienced on the PHD. To state that more generally: what is the System One equivalent to a Hemodialysis Product (HDP)= 100?

A HDP = 100 on the PHD required about 3.5 hours a day gross (treatment time + pre + post). My current System One regime is taking five + hours gross, HDP unknown. Looking ahead I think I’ll try to multi-task the treatments by either working (telecommute, doing CAD for a company that sets up conventions and trade shows) or sleeping i.e. nocturnal or some combination. The lifestyle goal is to get to bed after walking the dog before 11 PM (ideally 10 and read in bed) and up at 6:30 AM well rested and well dialyzed. I’ll get there.

Bill, I understand the frustration in trying to find that perfect mix of adequate clearance and minimal time. It is my understanding that the real purpose of running the low dialysis speeds was to minimize the amount of dialysate that they were shipping out before the pureflow was available. (that may not be 100% accurate, but go along for a moment).

It is also my understanding that your clinic pays the same monthly amount for your system one, pureflow and supplies whether you use 20L per treatment or 60L per treatment.

As I posted somewhere (I think it was on this board) we checked kinetics on 15L running FF of 33 and the next day tested 20L at FF of 38. (Before the pureflow, my wife was on 15L of bagged dialysate.)The 15L gave us a kt/v of 1.9. The 20L gave a kt/v of 2.4. Quite a bit of difference.

My point is, you probably aren’t married to your volumes and rates. It won’t cost any more to run 60L a treatment and speed up the FF to get your time down. I don’t know that is the answer, but get with your nephrologist and see if they are agreeable to you making a few changes. What’s it gonna hurt?

Bill,

This was very informative. Thank you. I’m confused about one thing. I know in other posts you indicated your size - but I’ve forgotten it.

Why are you on the System 1 for 5+ hours? I believe I read you are running 6 days/week. I weigh 90k and on average dialyze for 140 minutes/day times 6 days generally and utilize 20L of fluid on the Pureflow. I realize everyone is different and results are based on the individual. I average kt/v’s of 2.4 with this regime and ff 32.

Will you elaborate on why you are running so long. I’m sorry if I missed it in your post.

Also, I know you are recovering from some difficulties. Can you tell a difference in how you feel yet - between the two machines?

Thanks, Erich