A few weeks back I published my blog entry – Helpful Tip – How to Correct a Recurring Error 35

Since then I have had a a number of treatments where I had a series of recurring error 35’s. Becoming tired of flushing the blockage out of the effluent line with a 60ML syringe and tap water during treatment, I spent a little more time analyzing why this was occurring.

When my NxStage was originally installed in May, 2010, the effluent line -, the black plastic line that runs from of the back of the NxStage unit to the waste in my bathroom was run not cut to length. The excess line was simply looped in about a three foot circle in the bathroom just before it drains.

This large loop of excess line was acting like the elbow in a sink drain where particles collect at the bottom of the circle, and after enough time block the line from working properly. Today I cut over four feet from the line. It’s now the proper length, and drains directly without any excess, or the large circle of line.

I’m certain this will correct my recurring error 35’s, but if it doesn’t, my dialysis center let me know they can provide a replace effluent line.

Six years ago today I had my donated kidney removed based on a life-threatening arterial infection. I had my donated kidney and pancreas transplant for nine months. My pancreas transplant never worked, but the kidney was working great for me.

The arterial infection was preventing blood flow to the kidney, so I had to decide if I wanted to lose the kidney or my left leg. I remember telling the doctor a working kidney was great, but I would rather keep walking.

After opening me up they found so much abdominal infection, they told my wife they literally bathed my abdomen with bleach. The infection did so much damage, I also had to have a femoral artery bypass from my left right leg to my left leg.

Post-surgery I continued to have problems with infections, and had to learn to walk again. Three months later I returned to work, and dialyzed in-center three time per week.

What a life change. Severe limitations on how much I could drink, tired all the time, hardly able to climb a single flight of stairs, even more diet limitations with potassium and phosphorous.

After being in-center for about a year and a half, I discussed my life expectancy with my Nephrologist and was shocked to learn the average patient lives from six to eight years. I recall telling him “that’s not going to work for me, I have two kids in college and a home mortgage.”

We then discussed the health benefits of more frequent dialysis via home hemo and NxStage. Within a short time I had a button-hole fistula to make self-cannulation easier, and after another month I began training on the use of NxStage equipment.

Today I feel much better, I have much normal blood levels of potassium and phosphorus, I have more energy, and I feel much more in-control of my health and life because of NxStage home hemodialysis.

It has been a life-saving change for me, health-wise, physically and mentally. Friends and relatives always tell me how great I look for a man on hemodialysis. I still tire very easily because of low hemoglobin, but with frequent injections of Epogen, I have more energy than I did when dialyzing in-center.

I feel like the luckiest man alive, I survived the arterial infection that should have killed me, and now due to six-days-a-week home hemo via NxStage, I expect to celebrate many future home hemo anniversaries.

If you run on a NxStafe System you will become very familiar with the usual warnings and errors and how to resolve them.

A problem I have begun having more and more frequently is a recurring error 35. Error 35 – Check Waste Line: Waste Line Pressure High (Red Alarm). This error indicates the waste line is occluded (or blocked).

Sounds simple enough, either the effluent line has become clamped, blocked or crimped. Simply find and remove the problem.

Well, after using the NxStage for almost five years, more and more waste blockage forms in the line that runs from the back of the NxStage to disposal. When I first started using the NxStage it was recommend that I clean the effluent line once per month with a 10% bleach solution and water. Later I was told to reduce the number of days between cleanings to ten days. Since then I have reduced it to nine days, but that was still not enough.

Yesterday while running I got my first error 35 when I had 21 minutes left to dialyze. I checked that all clamps were open, I had my partner check the end of the effluent line to ensure it was not blocked and restarted. I ran for one more minute and got another error 35. This is a red alarm that shuts down the pump, so it takes two minutes to restart.

Argh –  the dreaded addition of time to when I get off. Following the directions in the NxStage book, simply press stop, then restart treatment. After doing this I multiple times I continued to get another error 35 after each minute of treatment. Now my 21 minutes of remaining treatment would take over an hour.

To clear the blockage in the effluent line I had my partner fill a 60ML syringe with tap water, and add a connector to the end of the syringe, then stop the NxStage, clamp both yellow clamps on the effluent line, separate the connections at the yellow clamps, screw on the syringe, Note: make sure to connect the syringe to the short effluent line that  goes into the Pureflow, NOT the longer line that goes back into the cartridge, and then push all 60 ML of water through the effluent line that enters the PureFlow. When complete, disconnect the syringe, reconnect the effluent line, open both  yellow clamps, and restart treatment.

This procedure corrected the blockage in the effluent line and allowed me to complete my entire treatment without another error 35. And, I also changed the time between cleaning the effluent line from nine days to seven days to further prevent this from recurring.

You may also find my blog entry on Do You Need to Shorten Your Effluent Line helpful with resolving recurring error 35s.

NxStage warning 24 is arterial pressure that’s too high, its reset by simply pressing the yellow alarm reset button. Error 25 is a hard machine stop for arterial pressure that’s too high and forces you to Stop and Restart the unit. In addition to halting the NxStage unit, high arterial pressure is dangerous for your fistula. Both of these errors require that you correct the problem that’s causing them, or reducing your run speed.

I’m lucky, I have a great button-hole fistula, and normally run at 500 speed with my NxStage dialyzer. I start at 350, advance to 470 with the first couple of minutes and most of the time I am running at 500 within the first 15 minutes.

Why run at the fastest speed? The faster the run speed, the higher the dialysate rate. These two factors determine how long you will be on the machine. If you’re like me, the last 30 minutes of dialysis seem like hours. Anything that reduces this time is GREAT.

Every now and then I have trouble getting much over 470, but why? The obvious issues are needle placement in your fistula. Sometime simply adjusting the arterial needle will allow faster speeds.

When I first started at home, I frequently had to “prop” my arterial needle. I used three 3”X3” cotton swabs rolled up to form a one inch round pad that I placed under the tabs of the needle to allow a faster run speed. Luckily I only needed this for a few weeks.

About a week ago I again had trouble getting to my usual 500 run speed. After reviewing both the arterial and venus lines, I discovered that if these lines were crossed one or more times, it slowed my run speed. Also I use two pieces of tape on the bicep of my fistula arm to hold the needles and lines in place, if these pieces of tape are too tight, it can reduce blood flow, and run speed.

I also check to make sure there aren’t any unusual kinks in the lines, anywhere between my arm, and their entry back into the NxState unit. I only takes a very slight kink or sharp turn to reduce blood flow, and run speed.

Lastly I carefully inspect my needle sets. If I find one that has unusual curves in the tubing portion of the line, I only use them on the venus line, and save the perfectly straight lines for use in my arterial side.

As I mentioned in one of my earlier posts Have Your Fistula Checked if trying these steps still won’t allow you to get to your normal run speed, it might be time to have your fistula checked by an Arterial Surgeon.  Clotting or narrowing of your fistula can also cause loser run speeds.

Over time, you will learn what minor issues can reduce run speed, and become very adept at correcting them and completing your dialysis run as fast as possible.

I have had chronic high blood pressure throughout my life – until I started hemodialysis. Prior to hemodialysis I took the maximum dose of 12 blood pressure medications daily. Today I take half of one drug – catapres (clonidine), and have fairly good control of my blood pressure. What’s the downside? Nearing the end of dialysis I have dangerously low blood pressure.

What causes this problem, and what can be done to help reduce it? As water is removed from your blood cells by hemodialysis your blood pressure drops. The more water you remove the more your blood pressure is lowered. Another way your blood pressure is reduced is eating within four to six hours of dialysis. And, everyone has lower blood pressure early in the day. Simply dialyzing at a later time in the day can increase your blood pressure.

Eating food too soon before dialysis reduces your blood pressure as your body moves blood from the rest of your body to your stomach to digest food and this lowers your blood pressure. I try to avoid eating a meal within four to six hours of dialysis.

I typically have problems during the last 30 minutes of dialysis. When dialysis is complete the NxStage unit rinses back your blood using .277 liters of saline. So the unit automatically adds the amount to the amount of water is takes off. Therein lies the problem, you are going that amount BELOW your dry weight nearing the end of treatment.

I have tried various methods for short term increase of blood pressure. They are all high in salt. But, a good side effect is that high salt also reduces the cramping in my legs that I also have when my blood pressure drops too low.

I have used chicken broth, the only downside is that you are drinking even more fluid that will have to be removed with dialysis. I mix one cube of chicken broth to half cup of water. This makes a very salty version of chicken broth, but it will raise your blood pressure and relatively quickly.

Others I use are dill pickles, but eating very many can be difficult, and my favorite – beef jerkey. I eat one when I start, then another after the first 30 minute machine check, and another 30 minutes later.

What if eating these items still don’t raise my blood pressure enough? The last option is to reduce the amount of fluid you are removing during dialysis, and/or adding saline.

So what’s the problem with low blood pressure? You can pass out, and can die from blood pressure that’s too low. Once you pass out, your dialysis partner only has a few seconds to give you saline to stop this process. My wife has had to do this for me twice during the first few months of dialyzing at home.

If I encounter low blood pressure more than once, it may mean that I need to raise my dry-weight. My nephrologist allows me to change my dry weight by up to .3 liter. I have not had to do this for more than a year, but it’s too dangerous to continually have low blood pressure while dialyzing.

Because I dialyze daily with the NxStage, I can easily take less off than I had planned on any given treatment, because I can just take off any excess the next day. This provides me with a lot of flexibility on the amount to remove on any given day.

The symptoms I encounter when starting to get low pressure are lightheadedness, sometimes my left calf starts cramping, which can become severe, and finally dizziness. It’s very important to know that at the first sign of any of these symptoms, check your blood pressure. By the time I feel lightheaded, I have about 30 seconds to react before I get in serious trouble. Because this usually happens to me during the last 30 minutes of treatment, I have become very good at recognizing and treating these symptoms.

From my completed flow sheets my ending blood pressures for the last few treatments were 92/59, 91/51, 102/52 and 79/45. On the last of these I had to both reduce the amount of water I was taking off and give myself saline.

Another important item I have discovered over the many times I have dialyzed at home is that my scale does not warn me when it’s battery is low, and it adds from .1L to .3L more to my weight. If I have low blood pressure during treatment for two days in a row, I change my scale batteries to correct this problem.

The good news is that over time, you will learn what causes low blood pressure, how it feels when you encounter it, and how easily it can be corrected before it becomes dangerous.

As I mentioned in my first post, I have been doing home hemo for four and a half years. Over that length over of time I have certainly had my share of saline and dialysate leaks.

Save yourself a lot of grief and tighten every connection each time you use a cartridge. 95% of the time the plastic connectors will be tightened at the factory, but when one comes loose during the prime process, you will leak saline in or on the NxStage unit. Of course, you can clear the error and clean up, but it’s a lot easier to just prevent this problem by re-tightening ALL the connections on the cartridge every time you use one.

The same is true for making a new batch of dialysate. The “chicken-foot” connection is connected to the dialysate SAK with a single connector, my experience has been that more times than not, this connection has not been tightened and must be before you continue making the SAK. If you don’t, you will eventually get a dialysate leak, which can be a lot of grief to correct.

I also tighten all three connectors on the end of the “chicken-foot”. Over the last few years I have never had one come loose, but over the last few months I have had two of them blown off during the completion of snap-and-tap, resulting in the loss of dialysate fluid.

Last, and most important, check that the caps on both of your needle lines are tight. I have even inserted a needle to find that there was no cap on the end, blood everywhere. As soon as I remove the needle sets from their packing I check that the cap on each line is tight.

One more tip – when you run from premixed dialysate bags, save the plastic screw-on caps from each of the bags you connect. They can come in handy in the future when you have a leak, and the cap you lost is rolling around on the floor.

When I was initially diagnosed with kidney failure my nephrologist asked if I drank Diet Coke. I said yes, and indicated that I frequently drank a dozen cans a day while working. He told me that Coke is the only soft drink that actually adds potassium as part of their recipe. And, since all colas are mode from cola beans, they are also very high in phosphorus.

I also love Italian food, potatoes, fresh fruit and vegetables, seafood, etc. All of these items also contain potassium, some at very high levels.

While dialyzing in-center a fellow patient told me how to tell what foods are high in potassium and phosphorus – if it grows, it’s high in potassium. If it tastes good it’s high in phosphorus.

Luckily, there is plenty of information online about the potassium and phosphorus levels of almost any food you can name. Here is one that I used frequently:

https://www.med.umich.edu/1libr/Nutrition/PotassiumHandout.pdf

https://www.med.umich.edu/1libr/Nephrology/Nutrition/UMHS_HighPhosphorusFoods.pdf

So, the bad news – I now know what foods are high in potassium and phosphorus, what can I do if I love these foods?

Dialysis removes potassium and a small amount of phosphorus. Never miss a treatment. By dialyzing six days a week at home, I have the ability to be much more flexible with my diet, and foods that contain potassium and phosphorus.

Meal planning goes a long way in allowing me to eat more potassium. When I crave a food high in potassium I eat them four to six hours before I dialyze, and the high potassium gets taken out of my blood almost as quickly as it enters it. Since I dialyze at 6:00 PM each evening after my wife returns home from work, I eat these types of food for lunch.

When I crave a high potassium food for dinner and know I won’t be dialyzing until 24 hours later, I used a prescription potassium binder called Kayexecelate. I only do this once or twice a month, but it provides me with just enough freedom to adhere very closely to my low potassium diet. My potassium level in my last monthly lab work was 4.5, well within the guidelines for the range of safe potassium blood levels. This works for me, but the use of Kayexcelate like this must be discussed with your nephrologist before using it in this way.

The most important thing to remember about potassium, both high and low levels are very dangerous for your heart.

Phosphorus is a different story. Even with daily dialysis, I still need to use a prescription phosphorus binder every time I eat. I have used Renegal in the past, and now use Renvella. These drugs can be very expensive, but without them you endanger your health.

Once on a two-day vacation with my wife, I forgot to pack Renagel. I stopped at a local pharmacy and purchased TUMS Ultra 1000 antacid tablets, and took them with each meal. These can be a used in an emergency to lower your blood phosphorus. But, in my case, use for more than a day or two also raised my calcium levels too high. Like any drugs, use of antacids as a phosphorus binder needs to be discussed with your nephrologist before any such changes.

I vary the amount of phosphorus binder I take with each meal, based on the amount of phosphorus in my meal. With a normal meal I use four 800Mg Renvella tablets. With a high phosphorus meal I will take seven Renvella tablets. After asking my nephrologist about the side effects of too much binder, he replied constipation. So, there is a balancing act with changes in dosage. My last phosphorus blood level was 4.5, also well within the guidelines for the range of safe phosphorus blood levels.

I am not providing medical advice. If you are considering any of the changes I have described, you must discuss them with your nephrologist prior to making them. But for me, sometimes “cheating” on my diet with foods higher in potassium or phosphorus allows me to closely adhere to a diet low in them the rest of the time.

With Thanksgiving only a couple of more days away, I know I will be enjoying a nice helping of mashed potatoes and gravy and my potassium level on Friday will still be normal.

I setup my NxStage System One six times per week, every week for four and a half years. I am pretty good at it and can start and complete the entire setup in about 40 minutes. One additional item I do every day as part of my setup is exercise my fistula.

Right after I had the fistula surgery, both the surgeon and technicians at the dialysis center advised me to exercise my fistula using a squeeze ball. They indicated it would help develop my fistula so I could begin using it sooner.

Like most exercises I have ever started, once I was successfully using my fistula I stopped doing the exercises. Over time I decided I should continue them to ensure my fistula stays in great condition. For those of us on hemodialysis, it’s truly our lifeline.

I use a set of exercise balls from Gaiam that I found at Amazon.com. It includes three balls of varying resistance (low, medium and firm). I most frequently use the medium resistance ball. I complete 25 repetitions with each hand, and repeat that 10 times, for a total of 250 repetitions each time I dialyze.

This may sound like a lot, but it adds less than five minutes to my setup time. And, in addition to improving and protecting my fistula, it has almost completely eliminated the ongoing pain I had in both hands from severe arthritis.

Do yourself a favor and add this one additional step to setup.

I have a button-hole fistula, I had the fistula surgery in 2009 and began using it after about three months. I used it with no issues over the next year while I dialyzed in-center three time per week.

I began research into home hemodialysis using the NxStage System One, and decided I would prefer to use home hemo instead of in-center hemo. I also decided I would need a button-hole fistula to easily allow me to insert my own needles for home hemo.

My button-hole fistula was created by a Master Phlebotomist. Sharp needles are carefully placed for the best blood flow, then I dialyzed like normal. The same Phlebotomist inserts the sharp needles in the same holes she initially created each time I dialyzed for about 12 to 15 more times. This forms scar tissue to allow the use of dull fistula needles.

This also allows my fistula to last longer, sharp needles cause damage to the skin over the fistula and to the fistula. My button-hole fistula will allow it to last longer, provide me with much easier methodology for needle insertion, and for me, dull needles are MUCH less painful than sharp needles.

Three days ago I had my fistula checked by an arterial surgeon. After over four years of use I was having trouble placing my arterial needle. I was sure I didn’t have a clot, but couldn’t seem to find the proper track to insert the needle.

I called my dialysis nurse to discuss the problem I was having and she asked me to come in to check my fistula. She listened to it with a stethoscope and it sounded normal. She had me hold a needle and demonstrate the angle I used to insert the needle, and my “turn” (I have an unusual fistula that quires me to insert the needle about halfway, then perform about a 45 degree turn, before continuing the full insertion of the needle (See picture of my fistula from the arterial surgeon below).

She felt that I was not getting the proper final angle to complete the needle insertion. That night I used the angle she suggested and got the needle in much more easily. And, like usual, I ran at my normal run speed of 500.

She asked me when I last had my fistula checked by an arterial surgeon. I replied that I had not seen one since I had a clot removed in the venous portion of my fistula over 18 months ago. She was surprised and said I should have it reviewed periodically and made an appointment with the vascular center.

The arterial surgeon did an ultra-sound of my fistula, compared it to the photo taken during my prior visit, discussed the issues I was having and determined that my fistula was in great shape.

He described that button hold fistulas have a flap of skin at the end of the scar tissue, and that the flap had to be moved out of the way while inserting the dull needle, and that scar tissue changes over time. I was simply having some problems accounting for the changes in scar tissue. After reviewing the photo of my fistula with him, I am right back to easily inserting the needle.

He also told me I should have my fistula checked every six months to verify it is working properly, and to prevent having problems in the future. I now have my next review appointment scheduled.

He also provided me with the following important information about the three conditions for fistulas:

Green – All Clear – Everything is normal, keep up the good work

Normal thrill (vibration)

Blood flow rates normal

Venous pressures normal

Arterial pressures normal

Bleeding less than 15 minutes after dialysis

No problems getting needles in

No pain, redness or swelling

Clearance labs normal

Yellow – Caution – Ask dialysis nurse for referral to vascular center

Thrill (vibration) weaker

Hard to get needles in

Frequent alarms on machine

Bleeding more than 15 minutes after dialysis

Pulling clots during needle insertion

Inadequate dialysis (clearance)

Low blood rates

Cold or painful hand during dialysis

Arm or hand swelling

Red Zone – Access emergency – Contact vascular center immediately

Clotted access (no thrill/vibration)

Can’t put needles in

Broken or clotted catheter

Drainage at needle sites or incision

Signs of infection:

• Redness
• Swelling
• Pain
• Skin warm to the touch

It’s pretty simple to avoid any of these problems by simply having it checked periodically by an arterial surgeon.

I live in Mid-Michigan, it’s 6:00 PM on November 15, it’s 0 degrees outside, and 69.4 inside, as usual, I’m freezing as I dialyze. I adjusted the heat on my Pureflow to 20, the maximum setting, but I’m still freezing.

Why am I so cold? My saline is at room temperature, over 29 degree below my body temperature, and my blood volume is lower by the amount of blood circulating in the NxStage System one.

What else can I do? The best solution that I found to this problem is a Sunbeam Electric Throw. It was only $19.99 at Wal-Mart, the best $19.99 I have ever spent! If you don’t live near a Wal-Mart, I also found these on Amazon.com.

It’s large enough to cover me from chest to toe, but small enough to easily put on and use will I’m connected. (I have a button-hole fistula and use dull needles, so I have quite a bit of movement of both arms without the fear of infiltration). I considered a twin size blanket, but it was too large to use comfortably, and higher in cost.

The throw has three setting – Low, Medium and High. I use High when I first start, soon lower it to Medium, and eventually get to Low before I need to come off. For me this has been a great solution. I’m on my second Sunbeam Electric Throw. I wore out the first one after about four years of use, so it was still a great buy.

The other thing I have learned to do is place my liter bag of saline on a register for about an hour before I start the prime on my NxStage System One. This brings the temperature of the dialysate up to a much more comfortable temperature before I use it. If I will be away from home for an extended period of time before I return and setup for dialysys, no problem – I just leave the saline on the register for as long as I will be gone. The register doesn’t provide too much heat.

A word of warning – DO NOT HEAT DIALYSATE IN THE MICROWAVE, it changes the dialysate and would be dangerous to use. I know PD patients heat their dialysis fluid using a microwave, but hemodialysis dialysate is different and this method cannot be used.

For any of you that have the same cold problems I do, I hope these suggestions help.