What BFR is best for Nocturnal HHD?


Hi Dr Agar,
I’m thrilled to find this sight! My husband and I just completed our HHD with our center in Central VA, USA, University of VA Dialysis. He started dialysis by doing the HHD training at the first sign of uremia due to kidney failure secondary to diabetes. He has never done in center.
We have a NxStage System One S machine. Our training thus far has been very good I feel. I am a Critical care RN of 30 + years, which makes me need to know why we do the things we do! Our trainers (nurse and NxStage rep) told us to use a BFR of 300-350 for home nocturnal. My husband has a healthy new mature fistula. He weighs 120kg dry weight.
Many of the HHD community based FB pages I follow mention they use a BFR of 200-280 for nocturnal HHD. They were appalled when I said I was trained to use a BFR of 350. I am trying to understand how the BFR is determined and what is the best BFR to use for safe and effective HHD on the system we will be using. My husband will be heparinized of course . Can you help us understand this?


Dear ‘Blue’

I am glad you have found the HDC site useful. It is the most useful site you will find.

The Medical Education Institute, via its’ HDC primary, offers a number of varied options … among its’ many information avenues are the HDC Kidney School, the HDC blog site KidneyViews and the HDC Facebook site.

I think you may find KidneyViews may best suit your current search for information, but all have value in different ways. My concern is that the Facebook site, while offering patients a place to air and share their views, sometimes gathers individual patient opinion that can be misleading - or incorrect - and though we do attempt to moderate it, it is also important to allow patients to say their piece, even if sometimes that misses the mark.

KidneyViews is written as an educative tool. It is a weekly blog page and I have written more than 70 blogs at it over the past few years, as have many others. The blogs are written by experienced dialysis personnel with long track records in the field of home dialysis.

To the point of your question, you may wish to start with a small sample of the hundreds of weekly blogs … can I suggest as starters, you might read the following:

  1. https://homedialysis.org/life-at-home/articles/blood-pump-speed-and-your-dialysis-fistula
  2. https://www.homedialysis.org/news-and-research/blog/237-don-t-flog-the-fistulas
  3. https://www.homedialysis.org/news-and-research/blog/228-blood-flow-rate-fistula-integrity-and-optimal-clearance
  4. https://www.homedialysis.org/news-and-research/blog/155-haemodialysis-uf-em-volume-em-and-uf-em-rate-em-are-not-the-same
  5. https://www.homedialysis.org/news-and-research/blog/27-dialysis-waterfall-forget-urea
  6. https://www.homedialysis.org/news-and-research/blog/29-dialysis-waterfall-part-2

These should get your inquisitive juices flowing! Sadly, US dialysis has much to learn, but takes little heed of practices in other countries. If they did, they might improve their currently worst-in-class performance.


Blue, Dr. Agar has done a fabulous job of alerting you to MEI resources! <3 And, kudos to you for finding your way to the best dialysis so quickly, in the face of what must have been a tremendous shock. I am not a clinician; I learn from Dr. Agar and from my other mentors in this field for the past 30 years. If it were me, and my husband, I might be tempted to experiment a bit with the blood flow rate. 350 is not terrible. 300 is likely better. And, perhaps 280 or 250 might suit you. The trick is to keep the blood flowing–you don’t want to dialyze so slowly that blood clots occur, even with heparin. But, you certainly don’t want to run (for any form of hemodialysis) at 450 or 500, which, shockingly, far too many people do. The problem is–though Dr. Agar will explain it in more depth in the blogs he pointed you to–that rapid blood flow creates turbulence inside a fistula that can lead to tissue remodeling and stenosis. No reason to go there if you don’t have to.


Thanks so much Dori, I plan to read all he suggested!


Thanks Dr Agar, that is a great help! Since my husband lost his renal function this expert cardiac nurse is smitten with nephrology, who knew the kidneys were so important?! :stuck_out_tongue_closed_eyes:
Thanks again!


As an experienced HHD user (and fellow blogger at HDC) I would like to add that preserving his fistula is more important than running a igh BFR. You can gain better clearance by using as much dialysate as possible. Your husband is rather large which is a great reason to use as much dialysate as possible under the circumstances. That and long treatments which you guys are already planning.
One last word of advice. If it’s difficult for him to sleep in the beginning, please push through it. I know Mike Kraus, CMO at NxStage, used to recommend trying for at least 6 weeks before making a final decision, something I totally agree with.


Thanks so much Henning!


I have blogged so many that they blur, but I think I may have found the one that explains blood flow rate vs. dialysis flow best …

Read … https://homedialysis.org/news-and-research/blog/228-blood-flow-rate-fistula-integrity-and-optimal-clearance

You may need to read, think, read again, then read a third time … esp. as you come to grips with the graphs - thats never easy - but spend some quality time with this blog and you will get it !

And thanks, Henning … NOTHING I can or do say can hold a candle to the voice of experience. You, and others who have been there, are there, and are doing it, every day, outweigh my bleatings, every time.


Thanks Dr Agar, have a great day!