When we established the Cheshire and Merseyside Kidney Information Network (CaMKIN) one of the first suggestions on the CaMKIN Facebook Group was a facility to have regular Questions and Answers sessions from patients to the Multidisciplinary Team (MDT) at Royal Liverpool. This page is devoted to those Questions and Answers sessions.
Questions and Answers
The first set of questions were posed to Patti O’Kane (RN), Deputy Network Nurse at Royal Liverpool and Broadgreen University Hospitals.
1. Does breaking the seal and mixing the fluid in APD bags several hours before overnight dialysis reduce the clinical effectiveness of the fluid?Sometimes I think it would be nice to set the machine up in the morning straight after disposing of the previous night’s used bags. Fresenius teach us that it is okay to set the machine up at tea time so long as we leave it a dry system.
Answer: The PD team at RLH suggest that it is ok to break the seal and mix the fluid in the APD bags in advance of overnight dialysis. They also support the advice from Fresenius that the system should be left dry and only primed when going on dialysis.
2. “I understand that a colder dialysis is generally better but I’m finding the cold intolerable during my dialysis session on the Fresenius 5008 at home, is there anything I can do to improve it?”
Answer: Assuming that the person is generally stable on dialysis and warming the dialysate
wouldn’t cause any hypotensive episodes we would probably advise them to increase the
dialysate temp by 0.5 of a degree to see if that helps. We would also advise them to wear
something a bit warmer or a blanket which could easily be removed if they became warm. It’s
always important to balance quality of treatment with quality of life. The rationale behind cooler
dialysis fluid is that research projects have shown that it helps to keep blood pressure stable and
can also improve clearance in dialysis.
3. Why do we not keep track of 02 as after 5hrs I feel like I’ve been boxing/running but none of the benefits and takes me 3-5hrs to recover?
Answer: Some dialysis clinics do monitor oxygen saturation at start and end of haemodialysis. However the symptoms that you describe are usually associated with the disruption that HD and HDF cause the homeostasis / balance within the chemical conditions of the body. The body keeps variables such as PH and solutes such as sodium, potassium, calcium within pre-set limits. To normalize these solutes and regulate ph, HD and HDF use diffusion to pull solutes from the blood into the dialysis fluid and down the drain. It takes at least 4 hours post dialysis for the body to re balance. This has the effect of making you feel as you describe.
4. Why when it’s been proved in every study that exercise improves Dialysis are we still sitting /lying for hrs doing nothing? Note from Rob Finnigan: It’s worthwhile looking at the Exercise on Dialysis Videos under the Get Active Section of Resources on the website.
Answer: At APH we have a dialysis ‘bike’ which can be used during dialysis. It has not been that well used over the last few years and is very expensive to buy but it is something that we are able to offer. Its benefits are documented to be better solute clearance, better fluid removal tolerance, long-term it can improve cardiac function and help build muscle mass in legs. We have recently started using it with a patient with restless leg syndrome with good success. Machine is called motomed Letto2 and we have it funded a number of years ago by the local League of Friends. Company can be contacted on the email below sales@medimotion.co.uk . There are plenty of other options which can be used- many of which are far cheaper. The advantages of the Letto2 over those are that it can be used while lying on a bed (many of the others only work with chairs), it has patient adjustable gears, a motor to automatically propel the legs which can help in patients with very poor muscle strength, multiple programs for leg strengthening, is able to record the distance travelled, calories burnt, effort put in etc. Please ask at your dialysis clinic as it may be possible to purchase equipment using charitable funds.
5. Is there no proper tools and data to show what percentage water we should be carrying as it seems like dry weight is mostly a guessing game.
Answer: It is not always easy to gauge a true dry weight and there is no one-size-fits-all way to measure it. It isn’t possible to offer a generic guide to the percentage of water you should be carrying, it varies from person to person and can be affected by age, sex, body size, other medical conditions etc.. Which can cause fluid accumulation and always involves a lot of clinical judgement to accurately assess. The tools/ assessments the nurses and doctors use to assess a dry weight are: blood pressure, fluid gains between sessions, signs of swelling (oedema) to the legs or elsewhere on the body, BVS/BVM/
Haemoscan (depending on machine) to assess fluid refill into the blood stream during dialysis. The doctors/ specialist nurses may also be able to hear any fluid in the chest using a stethoscope. The nurses would also ask how the person is feeling on dialysis, see if there is any drop in blood pressure or cramps during fluid removal, headaches etc. There is also the BCM machine which can help with dry weight assessment but that is a tool which isn’t available at every unit and so dry weight assessment/ prediction is usually based on an overall assessment of all the factors above. Not quite a guess, more of an educated prediction based on clinical assessment- it is not always easy to get right though.
5. Why do we still use Steel needles even though plastic cannulas have been around for 15
years.
Answer: I understand that this has been explored by consultant and vascular access nurse at RLH in relation to previous enquiry. Plastic cannulas have been used in Japan and Australia for a number of years. The research suggests that training to use plastic cannulas can take time. In addition the plastic cannula has a metal introducer so while this removed it is still needed to insert the cannula. The research using plastic cannulas is positive but as yet is not showing advantage over steel needles.
7. Why are patients always pushed into PD first rather than at least talking about HD either at home or in the unit.
Answer: Nobody should feel they are pushed towards any specific treatment. Information regarding the pros and cons of each of the suitable options should be given and then let the person make the choice. Ideally these discussions would take place many months before dialysis became necessary to allow the person the opportunity to discuss with friends and family and make the most appropriate choice for them. It often works well if patients and families are invited to open days where they can talk to patients that are currently on PD, HD etc. so they hear from someone with day to day experience. The GMKIN / CaMKIN Facebook pages aim to connect people so that they can share knowledge and experience
Research and patient outcomes would suggest that it may be more beneficial to start on PD and move to HD when PD is no longer possible. The national agenda is for “Transplant First”. However that’s not always possible.
PD has a lot of benefits for many people though (like preserving the remaining kidney function for longer than people who start on HD). This can mean less diet and fluid restrictions. PD can also be a more gentle treatment as it takes place more regularly and over a longer period of time) so a clinician may suggest this for its clinical benefits but ultimately the decision would always lie with the person. I agree clinical staff should always talk to all patients about a home therapy (home haemodialysis or PD). The patient should be given information to make an informed choice rather than the nurse or doctor deciding what is “best”. PD and more frequent HD (in centre or at home) have certain clinical benefits over 3 x a week in-centre haemodialysis (HD). Alternatively ShareHD can give patients back control / autonomy regarding their treatment if PD and home HD are not possible.
Whatever treatment a person is currently on there is often the possibility to change. Please speak to your nurse or consultant if you want to have more information on changing your dialysis treatment method.
8) Why do we no longer have disposable dialysis chair sheet covers? The dialysis chair I use needs a good deep clean.
Answer: Some clinics do use disposable chair covers. If you are a RLH patient at any of our satellite clinics I can look into having the covers at all clinics as currently they are only used at one clinic. Just as the moderator to give you my contact details. I would though hope to reassure you that all chairs are cleaned between patients. Please always raise any concerns with the staff. Unfortunately many of the wipes used to clean equipment do discolour and leave residue on equipment.
9) Why when doctor and renal staff carry out patient’s reviews and agree changes to dialysis or medication without the patient being present, the patient is not being informed with a letter to explain the reasons why?
Answer: I will answer first in terms of RLH and RLH satellite clinics. Every month the monthly blood results are reviewed and changes in treatment prescription are discussed. This is often referred to as the QA. Ideally any changes would be communicated verbally to patients. If at a Fresenius clinic they have a print out on Euclid that can be given to patients to take home. This tells them what their blood results are, what is normal and some information around the result e.g. phosphate. At RLH we are planning to introduce a similar handout. You can also access monthly blood results on patient view. These can be printed and shared at other appointments e.g. with GP.
Patients on in centre or satellite dialysis should also have a clinic appointment with a consultant every three months. A review of all medication usually happens at this appointment and you should receive a clinic letter as follow up.
At Arrowe Park there is a QA with the doctor/ pharmacist/ dietician/ sp nurses every couple of months and the consultant would discuss this with the patient at their next clinic review (normally done every 5 weeks). For any immediate changes one of us would speak to the patient at their next dialysis session and let them know what we had discussed. We don’t provide any formal letter from the QA at present- maybe that’s something we could look at doing in the future if the patients feel it would be of benefit?
Conclusion: We need to collaborate across the Trust to provide print out regarding monthly bloods.
To download and print a version of these answers, please click this link.
Questions and Answers, Session 2
The second session of Questions and Answers were posed to Dr Hameed Anijeet, Consultant Nephrologist at Royal Liverpool and Broadgreen University Hospitals and are available on the KIN website. They also can be downloaded by following this link.
Questions and Answers, Session 3
Session 3 was hosted by Hilary Brothwood, renal dietitian at Royal Liverpool Hospital and are available on the KIN website. They can also be downloaded by following this link.
