Dialysis In Kidney Disease

Carmody SagersAnna Johnson

Anna WillisLamli Lam

Review of Kidney Function

• Kidney is responsible for:– Filtering blood– Maintaining balance of fluid, electrolytes, solutes– Secreting renin to control blood pressure– Producing erythropoietin – Producing active form of vitamin D– Eliminating calcium and phosphorus

So what happens in kidney failure?

• High level of circulating waste products (azotemia)

• Decreased Glomerular Filtration Rate (GFR)• Shift in fluid and electrolyte balance• Cessation of production of hormones

These things lead to…

• Uremia – Malaise– Weakness– Nausea and vomiting– Muscle cramps and itching– Neurological impairment

• Edema• Renal osteodystrophy • Severe anemia due to lack of EPO

Treatment for Renal Failure

• Two options:– Dialysis• The process of diffusing blood through a

semipermeable membrane for the purpose of removing toxic materials and maintaining the acid-base balance• Two kinds: hemodialysis & peritoneal dialysis

– Kidney Transplant

Diagnosis

• Uremia• BUN >100 mg/dl• Creatinine 10-12 mg/dl

Prevalence

• As of 2008– 547,982 U.S. residents had ESRD• 205,724 of the cases resulted from diabetes

– 382,343 U.S. residents were receiving dialysis treatments

Comorbidities

• Diabetes• High Blood Pressure• Cardiovascular Disease • Congestive Heart Failure • Lung disease • Peripheral Vascular Disease• Malnutrition

Normal Ca/P Metabolism

• Maintenance of calcium-phosphorus homeostasis is an important and complex process

• Involves the interactions of parathyroid hormone (PTH), calcitonin, and active vitamin D

• The three main organs involved are the gut, kidney, and bone

Normal Ca/P Metabolism

• The kidney produces the active form of vitamin D and eliminates both calcium and phosphorus

• Active vitamin D promotes absorption of Ca by the gut and is needed for bone remodeling

• Vit D also suppresses PTH production, which is responsible for mobilizing Ca from bone

Normal Ca/P Metabolism

Ca/P Metabolism in CKD

• As GFR decreases, phosphorus is retained in the plasma and serum Ca levels decline

• Kidneys have a decreased ability to produce vitamin D decreased gut absorption of calcium reliance on PTH to main Ca levels through bone resorption

• Results in hyperparathyroidism, phosphate retention, and hypocalcemia

• In the diet, calcium intake must be kept high and phosphorus intake must be kept low

Ca/P Metabolism in CKD

Bone disease

Ca/P Metabolism in CKD

Dialysis

What is the purpose of dialysis?

• Removes waste from the blood• Removes excess water from the blood• Helps control blood pressure• Helps balance K, Na, Ca, and HCO3 – This depends on the electrolyte concentration in

the dialysate• Does not correct the endocrine functions of

the kidney

Properties of solutions

How does dialysis work?

• The dialysis membrane, keeps the blood separate from the dialysis fluid. – A thin layer of natural tissue (in PD)– A synthetic plastic (in HD)

• Dialysis fluid or dialysate is a plasma-like fluid where waste and excess water go when they leave the blood– These processes are called diffusion and osmosis.

How does dialysis work? (cont)

• Excess fluid is removed from the blood through ultrafiltration.

• In HD, the fluid is simply drawn from the blood by the dialysis machine.– The amount of water to be removed can be varied

by changing the dialyzer’s settings.• In PD dextrose is added to the dialysate to

draw water out by osmosis.

Hemodialysis vs. Peritoneal

• Hemodialysis-through dialysis needles and tubing connected to your arm blood is pumped through a dialyzer (artificial kidney) that cleans the waste products from your blood then returns it to your body

• Peritoneal dialysis- through a catheter dialysate is pumped into the peritoneal cavity, waste products diffuse from the blood into the dialysate. This fluid is withdrawn and discarded and new solution is added.

Hemodialysis

• External artificial kidney (hemodialyzer) connected to a dialysis machine

• 200 ml of blood goes through the machine at a time• Treatment 3x/week. Each treatment lasts from 3-5+

h• Home dialysis treatments can be daily for 1.5-2.5 h

or nocturnally 3x/week for 8 h• Surgery is necessary to create access to the

bloodstream

Dialyzer

Access to bloodstream

• Fistula- artery and vein are connected • Looped graft- artificial vessel is inserted– If patient’s blood vessels are too fragile

• Catheter- used until patient’s permanent access can be created or matured (can take several months)– usually short term

Access points for hemodialysis

Fistulas• enlarged vein (usually in your

arm)• created by connecting an artery

directly to a vein, allows greater blood flow into the vein

• As a result, the vein enlarges and strengthens, making the insertion of needles for hemodialysis treatments easier.

• Aneurysm- localized dilation of a blood vessel

• Anastomosis- surgical connection between two structures

Types of Peritoneal Dialysis (PD)

• Continuous Ambulatory PD (CAPD)– Requires no machine– Dwell time of 4-6h, 4-5x daily, 24h treatment– Process of draining and refilling takes about 30-40 minutes

• Continuous Cyclical PD (CCPD) or Automated PD (APD)– machine called a cycler to fill and empty your abdomen three to

five times during the night while you sleep.– In the morning, you begin one exchange that lasts the entire day.– You may do an additional exchange in the middle of the afternoon

without the cycler to increase the amount of waste removed and to reduce the amount of fluid left behind in your body.

Peritoneal Dialysis

CAPD Exchange

Peritoneal Equilibration Test

• Used solution is collected from one exchange to a 24h period to see the effectiveness of a dose of PD.

• This solution is compared to blood and urine samples from the same time period

• The peritoneal transport rate varies from person to person• Used to see how effective the current PD schedule is in clearing

the blood of urea. • From all the samples, one can compute a urea clearance and a

creatinine clearance rate-normalized to body surface area. • The residual clearance of the kidneys is also considered. Based

on these measurements, one can determine whether the PD dose is adequate.

Peritoneal Equilibration Test (cont)

• If the laboratory results show that the dialysis schedule is not removing enough urea and creatinine, the doctor may change the prescription by– increasing the number of exchanges per day for patients

treated with CAPD or per night for patients treated with CCPD– increasing the volume-amount of solution in the bag-of each

exchange in CAPD– adding an extra, automated middle-of-the-night exchange to

the CAPD schedule– adding an extra middle-of-the-day exchange to the CCPD

schedule– using a dialysis solution with a higher dextrose concentration

Choosing the right treatment

• Evaluate which treatment would work best with your lifestyle– There are pros and cons for each type

• Patients can talk with their physician about combining treatments– Some people use PD every day, but get HD once a

week if PD treatments are not removing enough waste from the blood

Pros and Cons of In-Center HD

• Pros• Facilities are widely available.• Trained professionals are with

you at all times.• You can get to know other

patients.• You don't have to have a

partner or keep equipment in your home.

• Cons• Treatments are scheduled by the

center and are relatively fixed.• You must travel to the center for

treatment.• This treatment has the strictest

diet and fluid limits of all.• You will need to take-and pay for-

more medications.• You may have more frequent ups

and downs in how you feel from day to day.

• It may take a few hours to feel better after a treatment.

Pros and Cons of Home HD

• You can do it at the times you choose-but you still must do it as often as your doctor orders.

• You don't have to travel to a center, more friendly for work and travel

• You gain a sense of independence and control over your treatment.

• Newer machines require less space and are portable.

• You will have fewer ups and downs in how you feel from day to day.

• Your diet and fluids will be much closer to normal

• You can spend more time with your loved ones.

• Pros • Cons• You must have a partner, who is also

trained.• Helping with treatments may be

stressful to your family.• You need space for storing the

machine and supplies at home.• You will need to learn to put in the

dialysis needles.• Daily and nocturnal home

hemodialysis are not yet offered in all locations.

Pros and Cons of PD

• Fit your treatment around your lifestyle• Independence – mostly you perform

the treatment yourself• Fewer visits to the dialysis unit (usually

once a month)• Works during sleep time for some

people• Continuous therapy is gentler and

more like your natural kidney function• Portable and flexible – easy to take

your treatment with you when you travel

• Less fluid and diet restrictions• No needles• Better blood pressure control

• Advantages • Disadvantages• You need to be well trained• Permanent catheter access

required• Some risk of infection• May show a slightly larger

waistline (due to carrying fluid)• Storage space required in your

home• Possible changes in your

appearance due to medications side effects

CAPD & CCPD CLINIC HD HOME HD

Can I do dialysis at home?

YES NO YES

Can I still work or attend school full-time?

YES NOT ALWAYS YES

Can I still travel? YES POSSIBLY POSSIBLY

Do I need to have needles inserted every time?

NO YES YES

Will it make me tired? POSSIBLY POSSIBLY POSSIBLY

Can I arrange my dialysis at convenient times?

YES POSSIBLY YES

Do I need to have equipment/supplies at home?

YES NO YES

Hemodialysis Peritoneal Dialysis Kidney Transplantation

In Center Home CAPD CCPD Deceased Living

Schedule Three treatments a week for 3 to 5 hours or more.

More flexibility in determining your schedule of treatments.

Four to six exchanges a day, every day.

Three to five exchanges a night, every night, with an additional exchange begun first thing in the morning.

You may wait several years before a suitable kidney is available.

If a friend or family member is donating, you can schedule the operation when you're both ready.

After the operation, you'll have regular checkups with your doctor.

Location Dialysis center. Home. Any clean environment that allows solution exchanges.

The transplant operation takes place in a hospital.

Availability Available in most communities; may require travel in some rural areas.

Generally available, but not widely used because of equipment requirements.

Widely available. Widely available. Transplant centers are located throughout the country. However, the demand for kidneys is far greater than the supply.

Equipmentand Supplies

No equipment or supplies in the home.

Hemodialysis machine connected to plumbing; chair.

Bags of dialysis solution take up storage space.

Cycling machine; bags of dialysis solution.

No equipment or supplies needed.

Training Required Little training required; clinic staff perform most tasks.

You and a helper must attend several training sessions.

You'll need to attend several training sessions. You'll need to learn about your medications and when to take them.

Diet Must limit fluids, sodium, potassium, and phosphorus.

Must limit sodium and calories. Fewer dietary restrictions.

Level of Freedom Little freedom during treatments. Greater freedom on nontreatment days.

More freedom to set your own schedule. You're still linked to a machine for several hours a week.

You can move around, exercise, work, drive, etc., with solution in your abdomen.

You're linked to a machine during the night. You're free from exchanges during the day.

Offers the greatest amount of freedom.

Level of Responsibility Some patients prefer to let clinic staff perform all tasks.

You and your helper are responsible for cleaning and setting up equipment and monitoring vital signs. Can be stressful on family helpers.

You must perform exchanges four to six times a day, every day.

You must set up your cycler every night.

You must take immunosuppressants every day for as long as the transplanted kidney functions.

Risk factors associated

• Peritonitis is still a common problem that sometimes makes continuing PD impossible.

• Here are some general rules:• Store supplies in a cool, clean, dry place.• Inspect each bag of solution for signs of contamination before you use it.• Find a clean, dry, well-lit space to perform your exchanges.• Wash your hands every time you need to handle your catheter.• Clean the exit site with antiseptic every day.• Wear a surgical mask when performing exchanges.• Here are some signs to watch for:

– Fever– Nausea or vomiting– Redness or pain around the catheter– Unusual color or cloudiness in used dialysis solution– A catheter cuff that has been pushed out

Cost of dialysis

• Dialysis is very expensive• The federal government (Medicare and

Medicaid) will pay 80% of the cost• Private health insurance or state medical aid

also help with the costs

Dialysis and Lifestyle

• We do not yet know how long patients on dialysis will live. We think that some dialysis patients may live as long as people without kidney failure.

• Many patients live normal lives except for the time needed for treatments.

• Dialysis centers are located in every part of the United States and in many foreign countries. The treatment is standardized.

• Many dialysis patients can go back to work – Jobs that require lots of physical labor may be too strenuous

Compliance

• At least ½ of hemodialysis patients are noncompliant and 1/3 of PD patients are as well

• It increases a patient’s risk of hospitalization and death

• The reasons most linked to noncompliance are psychosocial issues, younger age and smoking

• Treatment regimen can be modified to increase compliance

Dialysis and kidney function

• Does dialysis cure kidney disease?– No. Dialysis does some of the work of healthy

kidneys, but it does not cure your kidney disease. • You will need to have dialysis treatments for

your whole life unless you are able to get a kidney transplant.

Vocabulary Review

• Dialyzer• Diffusion• Osmosis• Ultrafiltration• Fistula• Dwell time• Exchange

Vocabulary Review

• Dialyzer- external artifical kidney• Diffusion- passage of particles through a semipermeable

membrane• Osmosis- movement of fluid across a semipermeable membrane• Ultrafiltration- additional pressure to squeeze extra fluid through

the membrane• Fistula- surgical linking of an artery to a vein, providing access to

blood vessels• Dwell time- how long dialysate is in the peritoneum• Exchange- Once diffusion is complete, all fluid and waste are

drained from your peritoneal cavity and replaced with fresh dialysate

Kidney Transplants

Transplants

A surgical implantation of a kidney from a• Living related donor- only need one donated kidney

to replace two failed kidneys• Living nonrelated donor• Deceased donor

Tissue type between the donor and recipient need to match.

Rejection of the transplant or infection secondary to immunosuppressive drugs are major complications.

Complications

This surgery can sometimes result in:

• Blood clots• Bleeding• Leaking or blockage of the ureter• Infection• Failure/rejection of donated kidney

Organ Donors

Those patients awaiting kidney transplants far outnumber the kidneys available to donate. The waiting time for a kidney transplant can be a year or longer.

Becoming an organ donor is fairly easy. Registration is done at a local driver’s license bureau.

www.shareyourlife.org

Medications for Transplants

Long-term medications• Glucocorticol steroids• Prednisone• Cyclosporine• Azathioprine• Mycophenolate mofetil• Tacrolimus• Sirolimus• Thymoglobulin• Atgam

The doses of these medications are decreased over time until a “maintenance level” is reached.

Corticosteroids

Associated with:

• Accelerated protein catabolism• Hyperlipidemia• Sodium retention• Weight gain• Glucose intolerance• Inhibition of normal calcium, phosphorus, and

vitamin D metabolism

Cyclosporine and Tacrolimus

Associated with:

• Hyperkalemia• Hypertension• Hyperlipidemia

MNT for Transplants

Protein• High protein diet for the first month• 1.3-1.5 g/kg• In cases of fever, infection, surgical/traumatic stresses-

increase protein requirement to 1.6-2 g/kg

Fluid• Must be monitored closely• While on dialysis, patients require a fluid restriction.

Transplant patients need to maintain fluid intake• Encouraged to drink 2 L/day, but overall needs will depend

on urine output

MNT for Transplants

Potassium• Cyclosporine is associated with Hyperkalemia• Restrict potassium intake• Usually temporary

Calcium and Phosphorus• Patient can get hypophosphatemia and hypercalcemia caused by

bone resorption• The diet should provide adequate amounts of calcium and

phosphorus• However, serum levels of these nutrients should be monitored

periodically• If hypophosphatemia does occur, supplement with phosphorus

MNT for Transplants

Triglycerides and Cholesterol• If these are high, calorie restriction is needed for those that are

overweight. • Cholesterol intake less than 300 mg/day• Limit total fat• Patients with glucose intolerance need to limit carbohydrates and

maintain a regular exercise program

Sodium• Moderate sodium restriction (80-100 mEq/day) during periods of

fever, infection, or traumatic stresses• Helps to minimize fluid retention and controls blood pressure

Post-Transplant Weight Gain

• Very common problem • This occurs with medication side effects, fewer

dietary restrictions, and no physical exercise• This problem can be combated by weight

management counseling • Avoiding/correcting this problem will contribute to

the longevity of the transplanted kidney

Rates of Survival

Living-donor kidney transplants• 98% of patients live for at least one year after

surgery• 90% live for at least five years

Deceased -donor kidney transplants• 94% live for at least one year after surgery• 82% live for at least five years

Medications for Dialysis

Phosphorus Medications

• Commonly used are phosphate binders, including:Calcium Carbonate (TUMS, Calci-chew)Calcium Acetate (PhosLo)Sevalamer Hydrochloride (Renagel)-reduces serum

phosphorus without raising serum calcium.Lanthanum Carbonate (Fosrenol)Aluminum hydroxide (AlternaGEL)

• Common side effects are: hypercalcemia (calcium-based binders), gastrointestinal upset, diarrhea, gas, severe constipation-which may lead to perforation of the intestine which can cause peritonitis or death.

Calcium

• A patient can develop hypocalcemia and hyperphophatemia. Because calcium is in the dialysate bath, the level of calcium can be increased or decreased.

• Decreased calcium would aid patients who have developed hypercalcemia from active vitamin D administration.

• Patients who get too much calcium can develop calciphylaxis which is when calcium phosphate is deposited in soft tissues.

• Calcium is increased with supplements:calcium carbonatecalcium acetatecalcium lactate, malate, or gluconate

• Calcium also increased with the 300-500 mg provided in the diet. • Starting calcium supplementation early can prevent

hyperparathyroidism.

PTH lowering drugs

• Active vitamin D (available as calcitriol, caltrol, and calcijex)-to treat hypocalcemia.

• Hectorol and Zemplar-lowers PTH and raises calcium levels.

• Cinacalcet (calcimemetic)-a calcium imitating drug that binds to sites on the parathyroid gland which gives the gland a false impression that calcium levels are elevated.

Overview of Drugs

• Phophate bindersCalcium carbonateCalcium acetateSevelamer hydrochlorideLanthanum carbonateAluminum hydroxide

• IronIV iron (iron dextran, Aron gluconate, iron sucrose

• ErythropoietinIV or IM (Epogen or EPO)

• Activated Vitamin DOral (Hectorol)IV (Calcitriol)

• BiphosphonatesOral (Alendronate-fosamax)IV (Pamidronate)

Overview of Drugs Cont.

• Calcium supplementsTUMS, Os-Cal, Calci-chew

• Phosphorus supplementsKphos, NutraPhos, NutraPhos K

• CalcimimeticsCinacalcet

• Heavy Metal Chelator- binds aluminum and iron and is dialyzed off

IV Desferal (deferoxamine or DFO)• Cation Exchange Resin-for hyperkalemia

Oral or rectal (sodium polystyrene sulfonate or SPS)

Renal Osteodystrophy

• Three types:Osteomalacia (bone demineralization)Osteitis fibrosa cystica (caused by hyperparathyroidism)Metastatic calcification of joints and soft tissues

• A fourth type unique to renal failure patients on active vitamin D is low turnover bone disease. This bone disease is characterized by the oversuppression of the parathyroid gland with too much active vitamin D. It causes decreased bone formation and fragile bones with very little matrix.

• Control these conditions with the drugs discussed above.

Medical Nutrition Therapy

MNT Goals

• To prevent deficiency and maintain good nutrition status

• To control edema and electrolyte imbalance• To prevent or retard the development of renal

osteodystrophy• To enable the patient to eat a palatable,

attractive diet that fits his/ her lifestyle

Nutrient Requirement Chart

Kcal Protein Fluid Sodium Potassium Phosphorus

Hemodialysis35 kcal/kg

IBW 1.2 g/kg

750-1000 ml/day +

urine output2000-3000

mg/day2300-3100

mg/day 0.8-1.2 g/day

Peritoneal dialysis (PD)

30-35 kcal/kg IBW

1.2-1.5 g/kg

minimum of 2000 ml/day

2000-4000 mg/day

3000-4000 mg/day 0.8-1.2 g/day

Fluid Intake

• Limited fluid intake 750-1000 ml/day + amount equal to the urine output

• + Fluid from solid food: 500- 800 ml/day • Deal with thirst with drinking:– Sucking on a ice chips, cold sliced fruit, sour candies, using

artificial saliva, or chewing “sports gum”

Goals of fluid gain

• Hemodialysis: - 4 to5 lb fluid gain of body weight in the vasculature between treatments-equals 2% – 5% of body weight

• Peritoneal dialysis:- No fluid limited

Sodium

• Sodium restriction - 2000-3000 mg/day - no salt in cooking, avoids convenience foods- help to reduce thirsts and fluid intake - Conditions with salt-losing tendency need 3g or more sodium per day.

Potassium

• 2300-3100 mg/day for ESRD• 2000 mg/day for anuric patient• low-sodium foods & salt substitutes contain

KCl instead of NaCl• Food Sources: fruits and vegetables

Calcium and Vitamin D

• Increase calcium- Decrease ability of kidney to covert the

inactive form of vitamin D to , 1,25(OH)2D3 - Therefore cannot increase gut absorption of calcium

- Must rely on PTH to keep calcium level up through bone reabsorption

• Vit supplement – only Active D3 form

Phosphorous

• Restrict phosphorous intake: – 1200 mg/day or less– 17 mg/kg of body weight– Food source of P: dairy and meat

• Problem: – Calcium rich foods (milk) and high-protein diet are high

in phosphorous– Phosphate have high molecular weight– Phosphate-binding medication is required

Creatinine

• A normal waste product of muscle breakdown.• Can be controlled by dialysis. • Low creatinine level may indicate good dialysis

or low body muscle.

Iron

• Inability od kidney to produce EPO• EPO is a hormone that stimulates the bone

marrow to produce red blood cells and an increased destruction of red blood cells secondary to circulating uremic waste products

• A synthetic form of EPO, periodic IV, and oral iron are used to correct the anemia.

Water-Soluble Vitamins

• Water-soluble vitamins loss during dialysis- Dietary restriction (water-soluble vitamins are high in

K+ and P foods)- loss Ascorbic acid, niacin, riboflavin, and vit. B6- folate is highly dialyzable (supplement is recommended)- Loss of vit. B12 is minimal

• Fat-soluble vitamins do not loss much• Folic acid 3-6 mg/day • Vit. E supplement is not routinely recommended• Avoid vit. K supplements

Lipid

• Atherosclerotic cardiovascular disease is the most common cause of death among long term dialysis patients

• Although lipids lowering drug may have significant impact on management, treatment of hyperlipidemia still remains controversial.

Enteral Tube Feeding & Parenteral Nutrition

• Enteral Tube Feeding - ESRD patients usually doing well on

standard formulas- Refeeding syndrome may occur when

taking a low phosphorus level of the “renal” products• Parenteral Nutrition

- Used for malnourished patients with GI complications

Case Study

Case Study

• EJ• 24 y.o.f• Occupation: Secretary• Chief Complaints: anorexia, n/v, weight gain,

edema, malaise, SOB, pruritus, muscle cramps, inability to urinate

• Poor oral intake due to anorexia and n/v

Anthropometric

• Ht: 5’ (1.5 m)• Wt: 170 lbs (77 kg)• BMI: 33• IBW: 100 lbs• %IBW: 170

Biochemical

• Abnormal Labs:– Sodium 130 (L)*– Potassium 5.8 (H)*– Chloride 91 (L)*– PO4 9.5 (H)– Glucose 282 (H)– BUN 69 (H)*– Creatinine 12 (H)*– Calcium 8.2 (L)*– Cholesterol 220 (H)– Triglycerides 200 (H)*indicative of kidney failure

Clinical

• Overweight• Lethargic • Muscle weakness• Dry, yellowish brown skin• Generalized rhonchi with rales, SOB• Edema in extremities, face, and eyes• Elevated blood pressure (220/80)• Normal pulse, normal bowel sounds

Dietary Assessment

Usual dietary intake• Breakfast– Cold cereal, bread or fried potatoes, fried egg

• Lunch– Bologna sandwich, potato chips, Coke

• Dinner– Chopped meat, fried potatoes

• Snacks– Crackers and peanut butter

Dietary Assessment

• Current calorie order: 30 kcal/kg or 2300 cal/day• Estimated calorie needs: 23 kcal/kg or 1800

cal/day– HEB: 66.5+ (13.7*77)+(5*152)-(6.8*24)= 1700 cal

• Protein needs: 0.8 gm/kg• Fluid needs: 25 ml/kg or 1900 ml/day• Sodium restriction 2-3 g/day• Phosphorus restriction 8-12 mg/day

History

• Mom and dad both dx with type II diabetes• Type II diabetic for 11 years• Meds:– Glucophage– Vasotec

PES Statement

• Limited adherence to nutrition-related recommendations related to diagnosis of type II diabetes as evidenced high blood glucose levels, obesity, and stage 3 chronic kidney disease.

Nutritional Intervention

• Reeducate on importance of adherence to diabetic diet. Assess reasons for past noncompliance.

• Supplement diet with nutrition shakes• Encourage cessation of alcohol consumption• Educate on proper diet for renal disease (low

potassium, phosphorus, sodium)

Sample Diet

• Breakfast– 1 slice toast with margarine– 6 oz orange juice

• Snack – 1 cup cereal with 8 oz milk

• Lunch– 1 ham and cheese sandwich– 8 medium carrot sticks

• Snack– 4 graham crackers– 8 apple slices

• Dinner– 1 ½ cups stir-fried chicken with 1 cup rice– 1 cup sautéed green beans

• Snack– 1 dinner roll with margarine– ½ cup peach slices

References

• National Kidney foundation. Dialysis. http://www.kidney.org/atoz/content/dialysisinfo.cfm Accessed March 20, 2012.

• The Renal Unit. What is a dialysis fistula. http://therenalunit.com/what-is-a-dialysis-fistula.php Accessed March 20, 2012.

• Ben Franklin Technology Partners. Improving the Success of Kidney Dialysis.http://benfranklin.org/news/emv-technologies-improving-the-success-of-kidney-dialysis Accessed March 20, 2012.

• National Kidney Disease Education Program. Dialysis. http://www.nkdep.nih.gov/living/kidney-failure/dialysis.shtml Accessed March 20, 2012.

• National Kidney & Urologic Diseases Information Clearinghouse (NKUDIC). Treatment Methods for Kidney Failure. http://kidney.niddk.nih.gov/kudiseases/pubs/kidneyfailure/index.aspx Accessed March 20, 2012.

• Kutner N. Improving Compliance in Dialysis Patients: Does Anything Work? Sem Dial.14:324-327.• Baxter Healthcare. Dialysis Options.

http://www.baxterhealthcare.com.au/patients_and_caregivers/areas_of_expertise/renal/treatment_options.html Accessed March 20, 2012.

• Moriishi M, Kawanishi H, Tsuchiya S. Impact of combination therapy with peritoneal dialysis and hemodialysis on peritoneal function. Adv Perit Dial. 2010;26:67-70.

• PubMed. Dialysis. http://www.nlm.nih.gov/medlineplus/ency/article/007434.htm. Accessed March 20, 2012.

• American Kidney Fund. Treating Kidney Disease . http://www.kidneyfund.org/kidney-health/treatment. Accessed March 20, 2012.

References

• Medline Plus. End-stage kidney disease. http://www.nlm.nih.gov/medlineplus/ency/article/000500.htm. Accessed March 17, 2012.

• Wilkens KG, Juneja V. Medical nutrition therapy for renal disorders. In: Mahan LK, Escott-Stump S, ed. Krause’s Food, Nutrition, & Diet Therapy. 12th ed. Philadelphia: Elsevier; 2008: 922-955.

• PubMed. Comorbidities in patients with end-stage renal disease. http://www.ncbi.nlm.nih.gov/pubmed/12197927. Accessed March 17, 2012.

• Saliba W. Calcium and phosphorus metabolism in renal failure. J Am Board Fam Med. 2009;22(5):574-581.

• Oregon State University. Calcium and phosphorus homeostasis. http://lpi.oregonstate.edu/infocenter/minerals/phosphorus/phospth.html. Accessed March 19, 2012.

• New York-Presbyterian. Transplantation: KidneyTransplant. http://nyp.org/services/transplantation-surgery/kidney-transplant.html. Accessed March 16, 2012

• Organ Procurement and and Transplantation Network. Donor Matching System. http://optn.transplant.hrsa.gov/about/transplantation/matchingProcess.asp. Accessed March 16, 2012

• Mayo Clinic. Kidney Transplant. http://www.mayoclinic.com/health/kidney-transplant/MY00792/DSECTION=results. Accessed March 16, 2012

• Donate Life America. www.shareyourlife.org. Accessed March 16, 2012