Lessons from Across the Top 9 KidneyViews Blog Posts

This blog post was made by Dr. John Agar on May 30, 2024.
Lessons from Across the Top 9 KidneyViews Blog Posts

As a bit of Google Analytics sleuthing recently revealed that I wrote 9 of the 15 most-visited KidneyViews blogs over the past 6 years, I thought it might be useful to group those 9, distill their key learning points, and re-present them as a group. The key three take home themes—not surprisingly—are:

  1. Time

  2. Frequency

  3. Rate of volume change


Of these, I have come down on rate of volume change as the key message, for rate of change (of course itself a function of time and frequency) is the home dialyzor’s greatest single advantage—for health, well-being, and survival.

1. Haemodialysis UF Volume And UF Rate Are NOT The Same – June 9th, 2016

Key Learning Points:

  • For any given dialysis treatment, the volume to remove matters. But what is not as well understood is that it is that the rate of volume removal matters more—much more!

  • UF volume and UF rate are not the same thing.

  • The US recommendation for a UF rate of <13 ml/kg/hr is incorrect.

  • Current data suggests the volume rate safety level should be set at <8 ml/kg/hr.

  • The best way to achieve rate safety is by extending the duration of the dialysis session.

2. Explaining Haemodiafiltration (HDF) – January 21st, 2016

Key Learning Points:

  • Haemodiafiltration (HDF) adds convective clearance to the established principles of diffusive dialysis, and enhances middle molecule clearance.

  • HDF is commonly used in Europe, Australia, and New Zealand, but not in the US.

  • As HDF requires re-infusion of fluid into the patient across the dialyser membrane, a higher standard of water purity must be used.

  • HDF offers improved mortality outcomes when compared to standard HD.

3. Heading Off The Dreaded Cramp! – August 24th, 2017

Key Learning Points:

  • Dialysis cramps are common in the US where short dialysis is practiced, but uncommon where longer dialysis treatments are routine.

  • The rate of solute and volume (fluid) removal are key determinants of cramp frequency and severity.

  • Slowing down the UFR by applying tighter limits on fluid gains (= always difficult) OR extending treatment time (= ought to be easy) work best.

  • While clonazepam can be useful, it is not treating the cause.

Authors Note: We suggest that you read Blogs 4 and 5 together as they carry complementary messages.

4. Don’t Flog The Fistulas: Slow Hemodialysis Blood Flow! – March 14th, 2014

5. Blood Flow Rate, Fistula Integrity, And Optimal Clearance – October 26th, 2017

Key Learning Points:

  • There is minimal useful additional solute clearance by turning up blood flow rate (read pump speed) to >350 ml/min.

  • Carefully study this graphand read the explanation in blog 5.

  • Kt/V – itself a flawed and over-stressed measure—is not significantly enhanced by pump speeds >350 ml/min.

  • Higher blood flow rates (>350 ml/min) simply—and unnecessarily—increase venous return back into the fistula.

  • High rates of venous return disturb laminar flow patterns in the venous limb, causing turbulence and endothelial damage—and promoting stenosis

  • There is no advantageand every disadvantagefrom high pump speeds. Long, slow frequent overnight home HD (NHHD) is best at a maximum BFR of 225-250 ml/min.

6. Dialysis Waste Management: Why Won’t Anybody Listen? – April 28th, 2016

Key Learning Points:

  • A Cri-de-Coeur for environmental sustainability.

  • Dialysis is the most resource wasteful and waste-creating of all medical therapies.

  • Equipment manufacturers, providers, medico-nursing professionals, patients, and carers—all who are involved in dialysis—share a responsibility to reduce the environmental footprint of dialysis.

  • This blog details ways—both large and small—whereby each can make a difference.

7. The Mathematics Of Dialysis Vs. Two Normal Kidneys – December 1st, 2016

Key Learning Points:

  • A key blog that shows why, truthfully, dialysis cannot/will not return full and normal health.

  • Demonstrates the impact of time and frequency on dialysis delivery.

  • Compares the functional “grunt” provided by various dialysis modalities—e.g.: centre vs. home vs. long frequent nocturnal— with the function generated by two normal kidneys …and why dialysis always comes up (very) short.

  • A sobering read for those who expect dialysis to restore “normal” renal function.

8. “Poo And Goo”…Dialysis Effluent And The Septic Tank –  June 12th, 2014

Key Learning Points:

  • This blog is a practical learning point for home dialysis patients.

  • Helps to better understand how to dispose of effluent waste.

  • Not all septic systems “appreciate” dialysis effluent – this blog explains why.

9. A Primer On Haemodialysis “Weight” – May 4th, 2017

Key Learning Points:

  • An essential blog for those trying to better understand what weight, fluid, volume, and weight gains and losses all mean

  • An explanation of all the many, various (and confusing) terms used to describe ‘weight’ in dialysis.

Summary ..take home messages

Of the three principles messages that run through many of these blogs—time, frequency, and rate (or speed) of volume change—from a symptom and safety perspective, rate matters most. But, rate depends on time and frequency, so all are interlinked. The rest is “white noise.”


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