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DIALYSIS:
HOW DOES IT WORK?
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor, professor
of academic medicine, and medical author. He
graduated from Ross University School of Medicine
and has completed his clinical clerkship training in
various teaching hospitals throughout New York,
including King’s County Hospital Center and Brookdale Medical Center, among others. Dr.
Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and
instructor for Kaplan. He has developed several medical courses and curricula for a variety
of educational institutions. Dr. Jouria has also served on multiple levels in the academic field
including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject
Matter Expert for several continuing education organizations covering multiple basic medical
sciences. He has also developed several continuing medical education courses covering
various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the
University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an emodule training series for trauma patient management. Dr. Jouria is currently authoring an
academic textbook on Human Anatomy & Physiology.
Abstract
Healthy kidneys eliminate waste and excess water from our blood, but when
kidneys stop doing their job because of illness or injury, dialysis offers an
artificial alternative to ensure that patients stay healthy. Depending on the
patient’s specific illness or injury, dialysis may be a chronic need or may only
be required temporarily until the kidney is healthy enough to function. This
course offers a closer look at how dialysis functions within the body.
Continuing Nursing Education Course Planners
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William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,
Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner
Policy Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses. It is the policy of NurseCe4Less.com to
ensure objectivity, transparency, and best practice in clinical education for
all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 1.5 hours. Nurses may only claim
credit commensurate with the credit awarded for completion of this course
activity.
Statement of Learning Need
Patients with end-stage kidney disease requiring dialysis need health
professionals to explain the purpose and general differences between
hemodialysis and peritoneal dialysis to understand options for treatment.
Course Purpose
To provide nursing professionals with a basic knowledge of hemodialysis and
peritoneal dialysis.
Target Audience
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Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Activity Review Information
Reviewed by Susan DePasquale, MSN, FPMHNP-BC
Release Date: 1/1/2016
Termination Date: 3/24/2018
Please take time to complete a self-assessment of knowledge, on
page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned
will be provided at the end of the course.
1. True or False: Hemodialysis normalizes electrolyte levels but it
does not normalize the pH level in the blood.
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a. True
b. False
2. Once the person reaches a point where the kidneys are
functioning at less than ____ of normal, that person is said to
be in end-stage renal disease.
a.
b.
c.
d.
40%
51%
15%
10%
3. The nurse’s role when caring for dialysis patients include(s)
which of the following:
a.
b.
c.
d.
know the signs and symptoms of infection
know what laboratory studies may be ordered
understand what body areas to assess for infection
all of the above
4. The length of the dialysis session varies but the typical amount
of time it takes to complete peritoneal dialysis is:
a.
b.
c.
d.
between 4 and 6 hours
between 30 to 40 minutes
between 3 and 5 hours
at least 8 hours
5. The ___________________ connects an artery to a vein for
dialysis, using a small tube that runs between to connect the
two vessels:
a. central venous catheter
b. arteriovenous (AV) graft
c. arteriovenous (AV) fistula
d. catheter
Introduction
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Dialysis is an essential form of treatment among patients with reduced
kidney function who have not responded to conservative forms of therapy.
Most people who have dialysis require it to avoid life-threatening illness that
could occur from the buildup of waste products and toxins in the
bloodstream that are normally excreted by the kidneys. This important
method of treatment can take several forms, each of which is fundamental
to the person who must use it.
The history of dialysis as a form of removing toxins and excess fluid from the
body can be traced back to the 19th century, in which chemists were
beginning to understand and experiment with different types of membranous
materials in order to remove wastes from the body. Most early experiments
were conducted in labs and on animals. It was not until the 1920s that
dialysis experiments were conducted briefly on humans. During World War
II, the practice of using a membrane and dialysate solution to resolve high
levels of urea in the bloodstream was continued through the work of a
physician in Holland named Willem Kolff.23 Since then, the practice and
procedure for dialysis has advanced to become the life-saving mechanism of
cleansing the blood and replacing the work of the kidneys that it is today.20
The Purpose Of Dialysis
The kidneys are essential organs that serve several functions, which keep
the body in a state of homeostasis. The kidneys help to regulate blood
pressure, maintain pH levels of the blood, create red blood cells, and support
bone health. The kidneys also act as a filter for waste products and excess
fluid that develops in the bloodstream. Without proper kidney function,
electrolytes such as sodium and potassium, as well as other compounds,
such as urea, can build up to toxic levels in the bloodstream.
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The kidneys may not work properly because of illness or acute injury. Acute
renal failure occurs when an illness or injury arises that causes the kidneys
to stop working normally. It can often be treated and reversed.
There are some people, though, who develop chronic renal failure, in which
the kidneys slowly lose their function and the condition is irreversible. Once
the person reaches a point where the kidneys are functioning at less than 15
percent of their normal capacity, that person is said to be in end-stage renal
disease.25
Dialysis may be necessary as either an acute or chronic treatment for when
the kidneys are not functioning. Acute dialysis may be necessary for some
patients who are significantly ill as a result of acute renal failure. Typically,
these patients are hospitalized and may receive dialysis to correct their
current conditions.6 For example, a patient who develops increased
potassium levels as a result of poor kidney function due to illness may need
emergency dialysis in order to correct potassium levels and to avoid cardiac
complications.
Chronic or maintenance dialysis is ordered for patients who need ongoing
treatment to correct fluid and electrolyte imbalances as a result of decreased
kidney function. Most patients who require maintenance dialysis are in endstage renal disease.6
Dialysate Function
Dialysate is a type of fluid used with both hemodialysis and peritoneal
dialysis. Dialysate is fluid that contains ionic compounds, including sodium
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and chloride, as well as glucose.29 It is used as part of the cleaning process
of the blood that takes place during dialysis. For patients undergoing
hemodialysis, dialysate is used in the dialysis machine to assist with
removing toxins from the blood. During peritoneal dialysis, dialysate assists
with diffusion of wastes across the peritoneal membrane to collect in the
peritoneum. In both kinds of dialysis, the dialysate is essential for proper
removal of excess fluid and waste from the bloodstream through the dialysis
process.
The concentrations of solutes found within dialysate fluid can vary,
depending on the patient’s condition. For those who have chronic kidney
disease and need regular dialysis, the concentration of electrolytes found in
the dialysate solution can be adjusted to fit a patient’s individual needs,
depending on that patient’s status. Additionally, concentration of dialysate
solution can be adjusted to make corrections for other problems that could
develop during the dialysis process. For example, a dialysate solution with a
higher concentration of sodium might be beneficial for a patient who is at
risk for hypotension during dialysis. As the sodium decreases plasma
osmolality in the blood, it protects the blood’s volume thereby reducing the
risk of a drop in blood pressure.3
Hemodialysis
The most common form of treatment for kidney failure, hemodialysis, is a
process that involves removing some blood from the body, cleansing it to
remove excess solutes and toxins, and then returning the clean blood back
to the body. By getting rid of excess solutes that the kidneys normally filter,
hemodialysis maintains a normal pH in the blood, as well as normalizes
electrolyte levels, preventing buildup of potentially life-threatening levels of
certain chemicals.10
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To remove the blood from the body for dialysis, the patient needs an access
site. During dialysis, the access site is cannulated and a needle is placed into
the access to draw the blood out. The needle is connected to dialysis tubing,
which carries the blood away from the body and to the dialysis machine.7
The dialysis machine uses dialysate solution as part of the cleaning process
to remove toxins and extra fluid. After cleaning, the blood is returned back
to the patient’s body.
The decision to start hemodialysis is made based on a number of factors,
including the patient’s level of kidney function, nutritional status, symptoms,
and overall quality of life. The decision to begin dialysis should be made well
before the patient reaches a point where kidney function is so diminished
that he or she experiences life-threatening complications.15
Risk of Infection
Patients who undergo hemodialysis on a regular basis are at increased risk
of infection because of the potential for introducing bacteria into the body
during cannulation. Additionally, patients who need hemodialysis may
already be immunocompromised and may have less capacity to fight an
infection if one develops. It is essential for healthcare providers who work
with dialysis patients to practice proper hand hygiene, use personal
protective equipment, and reduce the risk of patient infection by utilizing
hygienic measures when performing cannulation and using needles,
syringes, and vials.21
Nurses must understand the signs and symptoms of infection that can result
during hemodialysis. They need to be able to assess for changes, understand
what body areas to assess if infection develops, and know what laboratory
studies may be ordered, such as a complete blood count or blood cultures.9
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The Hemodialyzer
Also called an artificial kidney, a major component of the hemodialysis
process is the dialyzer. The dialyzer is within the hemodialysis machine and
acts as a filter. Within the dialyzer, the patient’s blood flows on one side,
while the dialysate solution flows on the other side.4 The blood from the
patient enters one end of the dialyzer and the dialysate that contains the
impurities from the blood is removed through a filter. As the blood moves
through the filter, the waste products and toxins are sifted and moved out,
while the important blood components, such as red blood cells, remain.
On another end of the dialyzer, clean dialysate solution enters, which cleans
the blood as it moves through the filter. Because the dialysate moves along
one side of the filter and the blood flows in the opposite direction, the blood
and dialysate only move alongside each other, but do not mix. Finally, the
cleaned blood flows out the other end of the dialyzer and back through the
tubing that is returned to the patient. The dirty fluid with the toxins and
waste is drained away.1 Most types of clinical hemodialysis processes are
considered high efficiency, and they use high-flux dialyzers, which means
that the process works quickly and efficiently, although it still takes several
hours to complete.3
Before starting hemodialysis, the patient must first have an access placed.
The access site is the place where blood is removed and then returned
through the process of hemodialysis. Placement may be done a few months
before hemodialysis even begins.15,16 The hemodialysis access must be
placed with enough advance time to allow the affected blood vessels to heal
before starting dialysis.
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Arteriovenous Fistula
One of the most common forms of access is the arteriovenous (AV) fistula.
The AV fistula is created several months before dialysis begins, in order for
the site to mature. An AV fistula is created through a surgical procedure to
connect an artery to a vein; it is typically placed in the lower part of the
arm. Once the AV fistula is working, the blood flow can be felt as a thrill on
the skin over the site.16 Once it is placed, an AV fistula can last for months
or years for dialysis.
Arteriovenous Graft
An arteriovenous (AV) graft also connects an artery to a vein for dialysis, but
the graft uses a small tube that runs between to connect the two vessels.24
An AV graft is suited for the patient who has poor circulation or small blood
vessels. The graft is placed under the skin of the lower arm; it also produces
a thrill on the skin over the site. The AV graft does not require as much time
to mature as the AV fistula and can be used within several weeks after
placement.1
Central Venous Catheter
A central venous catheter is another type of access that can be used for
hemodialysis. A central venous catheter is often used as a temporary
measure, such as when a patient is waiting for an AV fistula to mature
before use, although there are some people who use their central venous
catheters permanently. This catheter is a type of central line and is inserted
into a large vein, such as the internal jugular, the femoral vein, or the
subclavian vein.26 Catheters consist of a compartment that carries blood out
of the body to the dialyzer to be cleaned and another chamber that returns
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the cleaned blood to the body. They are typically covered with dressings that
need to be changed and kept dry to reduce the chances of infection.16
Peritoneal Dialysis
Peritoneal dialysis (PD) is another option for dialysis for patients with chronic
kidney disease. When compared with hemodialysis, peritoneal dialysis is not
as common of an option. According to Kallenbach, peritoneal dialysis is used
by only about 8 percent of patients with chronic kidney disease in the United
States.5 Peritoneal dialysis is commonly used as a form of home therapy but
may also be available for use in the clinical setting.2
Peritoneal dialysis uses the peritoneal cavity and its surrounding membrane
to collect waste from the bloodstream. During PD, dialysate fluid is infused
through a catheter in the abdominal wall. This fluid is held in the peritoneal
cavity, in a process called a dwell. During the dwell, excess fluid and waste
from the bloodstream passes through the membrane surrounding the
peritoneal cavity and enters the dialysate.
The peritoneal membrane is semi-permeable, in that solutes and waste from
the bloodstream can cross the membrane and enter the peritoneal cavity. In
this way, the peritoneal membrane acts as the dialyzer and the process
utilizes diffusion of particles, in which the solutes pass from an area of
higher concentration in the bloodstream to an area of lower concentration in
the dialysate to collect in the peritoneum during the dwell.12 At the end of
the dwell, the dialysate solution is then drained from the peritoneal cavity
and a new round of solution is infused again.
Peritoneal dialysis is often performed at home, requiring that patients who
use this form of treatment must learn how to perform the dialysis as well as
understand potential complications. This involves thorough education and
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abilities for practice given by a health care provider specializing in
nephrology, such as a dialysis nurse. Education should be ongoing, with
plenty of support, as conducting peritoneal dialysis can be challenging for
many patients. Effectively performing PD at home empowers individuals and
helps them to feel successful in their endeavors. In-home peritoneal dialysis
can improve quality of life for patients who would otherwise be tied to
regular sessions of exchanges at a clinic.19
Catheter Placement
Peritoneal dialysis requires placement of a catheter in the abdominal wall.
The catheter is needed for the exchange of fluid. Typically, a catheter for
peritoneal dialysis is made of silicone or another type of artificial substance
that is implanted through the skin into the wall of the abdomen. The
catheter is inserted so that one end stays within the abdominal cavity, while
the other end exits the body. The catheter can be placed through one of
several techniques, including ultrasound-guided placement, laparoscopic
placement, or blind placement.18
The catheter has two cuffs, both of which are deflated before placement.
During placement, the surgeon inserts the catheter into the abdominal wall
and threads the catheter down into the pelvic cavity. The distal end of the
catheter, known as the intraperitoneal portion, is the part that sits within the
peritoneal cavity. The middle portion is the intramural part of the catheter,
which is the section that is threaded between the exit site and the
peritoneum. The external catheter is that portion that is outside the exit
site.11 The first cuff on the catheter is near the peritoneum, while the second
cuff is near the exit site, where the catheter exits the body. Once the
catheter has been placed, the cuffs are inflated; these cuffs keep the
catheter inside the body in the correct position.
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Most peritoneal dialysis catheters exit near the umbilicus of the abdomen,
although in some cases, the catheter may be placed in a higher location.
This is called an upper abdomen or presternal placement. While the catheter
is placed higher, it is threaded down into the peritoneal cavity once inside
the body. The presternal or upper abdominal catheter placement may be
indicated for patients who need PD and who are morbidly obese, those who
already have a stoma from prior gastrointestinal surgery, or patients who
have abdominal wall abnormalities that affect the patency of the catheter.18
Once placed, the PD catheter can be used right away, although most people
wait a week or two before starting with dialysis after catheter placement.13
Once the catheter is placed, it is held in place with a cuff. Eventually, skin
tissue grows around the catheter placement site, which also helps to keep it
in place. The skin around the site must be monitored and kept clean to avoid
infection or irritation. The patient is taught to clean the catheter site with an
antimicrobial cleanser or other type of cleanser as directed by the physician.
It should be inspected with each cleaning and any sign of infection, such as
redness, swelling, pain, or foul discharge should be reported to a physician.
Although the site may be tender at first, the body eventually adjusts to
having the PD catheter in place and the skin should be soft and of a normal
color within about two weeks after catheter placement. The catheter site is
covered with a sterile gauze dressing that allows air to reach the skin. This
dressing should be changed each time the catheter site is cleaned. The
dressing not only protects the skin, but also keeps the catheter in place and
helps to protect it from becoming dislodged.
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The catheter is an essential part of the exchange done as part of peritoneal
dialysis. The dialysate is infused through the catheter to enter the peritoneal
cavity. It is clamped to keep it closed during the period of the dwell, and
then used again later to empty the fluid after the dialysis is complete.14
While necessary and helpful for PD, people who have a catheter are at
higher risk of infection at the skin site as well as peritonitis. Because the
catheter provides an opening from outside the body directly into the
abdominal cavity, bacteria that enter the catheter could lead to a serious
infection within the peritoneal cavity, potentially causing life-threatening
illness.
Dialysis Treatment
Despite the advantages of using home dialysis, such as cost reduction and
an improved quality of life,2 the majority of patients who use hemodialysis
continue to receive their treatments at dialysis centers, rather than utilizing
dialysis methods at home.20,22
Frequency of Dialysis
The number of times that dialysis is needed depends on the type of dialysis
used and the location of the treatment. Hemodialysis may be completed at a
hemodialysis center. Patients who attend dialysis centers are typically
scheduled for dialysis treatments approximately three days per week. The
treatments are almost always performed during the daytime and according
to the schedule of the dialysis center.
Alternatively, some patients can have hemodialysis at home, using a
specialized system that is available for use in the home. Before performing
home hemodialysis, the patient and his or her family must have training and
a great understanding of the process of hemodialysis, as well as knowledge
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of what to do if complications develop. Additionally, the patient and family
members should be able to contact a healthcare provider quickly if
difficulties develop.
Home hemodialysis can be performed at night while the patient sleeps. This
requires that the patient set up the machine to use before going to bed and
then cleans up and completes the process after waking up. In this method,
home hemodialysis may be performed seven nights a week.15 How often the
patient needs to have hemodialysis depends on his or her kidney function,
symptoms, lab results, and quality of life; and, the frequency of
hemodialysis is determined by a physician.
Since it is often done at home, peritoneal dialysis may be repeated often and
completed on a frequent basis. If a patient performs PD at home, he or she
can repeat each cycle four to five times each day. Because the dialysate is
infused and then held in the abdomen, the patient is able to be mobile and
not tied to waiting at a center for the process. Using continuous ambulatory
peritoneal dialysis (CAPD) allows the patient to be mobile during the dwell.
The patient who uses CAPD typically has three exchanges during the day
and then an overnight exchange.13
Dialysis Session Length
The length of the dialysis session varies between the type of dialysis
performed and the location where it occurs. Patients who use hemodialysis
can expect to spend between three and eight hours’ time having dialysis.
Dialysis centers offer hemodialysis for patients who need to come in for
treatment as ordered. Dialysis centers are usually free-standing centers,
units within hospitals, or separate clinics, each of which has highly trained
physicians and nurses who specialize in dialysis treatments.7 When a patient
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attends a dialysis center for hemodialysis, the process typically takes
between three and four hours if it is done during the day.
Some dialysis centers offer hemodialysis as an option overnight, termed
nocturnal hemodialysis.15 In this situation, the patient arrives at the dialysis
center and is set up to receive dialysis during the evening. The patient then
sleeps at the dialysis center and has hemodialysis at the same time. In this
method, hemodialysis may take several hours, or the entire night while the
patient is sleeping. Similarly, some patients utilize home hemodialysis for
treatment and, when used as nocturnal hemodialysis, the process can take
up to eight hours or the amount of time that a patient sleeps at night.
The amount of time it takes to complete peritoneal dialysis varies, but the
period of the dwell is typically between 4 and 6 hours. It may also take
another 30 to 40 minutes around the time of the dwell to infuse the
dialysate solution into the catheter and then to drain it again after the dwell
is complete.
Summary
Dialysis is a life-saving measure for patients who rely on this treatment
when their kidney function is no longer adequate to meet their bodies’
needs. Hemodialysis is the most common form of treatment for kidney
failure, and is a process that involves removing some blood from the body,
cleansing it to remove excess solutes and toxins, and then returning the
clean blood back to the body. By getting rid of excess solutes that the
kidneys normally filter, hemodialysis maintains a normal pH in the blood, as
well as normalizes electrolyte levels, preventing buildup of potentially lifethreatening levels of certain chemicals.
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Chronic or maintenance dialysis is ordered for patients who need ongoing
treatment to correct fluid and electrolyte imbalances as a result of decreased
kidney function. Most patients who require maintenance dialysis are in endstage renal disease. Whether dialysis is administered on a short-term basis
to correct an acute condition or is needed long term for chronic disease,
dialysis has a significant impact on those who use it as well as a great ability
to improve quality of life.
Please take time to help NurseCe4Less.com course planners evaluate
the nursing knowledge needs met by completing the self-assessment
of Knowledge Questions after reading the article, and providing
feedback in the online course evaluation.
Completing the study questions is optional and is NOT a course
requirement.
1. True or False: Hemodialysis normalizes electrolyte levels but it
does not normalize the pH level in the blood.
a. True
b. False
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2. Once the person reaches a point where the kidneys are
functioning at less than ____ of normal, that person is said to
be in end-stage renal disease.
a. 40%
b. 51%
c. 15%
d. 10%
3. The nurse’s role when caring for dialysis patients include(s)
which of the following:
a. know the signs and symptoms of infection
b. know what laboratory studies may be ordered
c. understand what body areas to assess for infection
d. all of the above
4. The length of the dialysis session varies but the typical amount
of time it takes to complete peritoneal dialysis is:
a. between 4 and 6 hours
b. between 30 to 40 minutes
c. between 3 and 5 hours
d. at least 8 hours
5. The ___________________ connects an artery to a vein for
dialysis, using a small tube that runs between to connect the two
vessels:
a. central venous catheter
b. arteriovenous (AV) graft
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c. arteriovenous (AV) fistula
d. catheter
Correct Answers:
1. b
2. c
3. d
4. a
5. b
References Section
The reference section of in-text citations include published works intended as
helpful material for further reading. Unpublished works and personal
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communications are not included in this section, although may appear within
the study text.
1. Dialysis Clinic, Inc. (2010). Hemodialysis. Retrieved from
http://www.dciinc.org/hemodialysis.php
2. Daugirdas, J. T., Blake, P. G., & Ing, T. S. (2012). Handbook of dialysis
(4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
3. Henrich, W. L. (2012). Principles and practices of dialysis (4th ed.).
Philadelphia, PA: Lippincott Williams & Wilkins.
4. Ahmad, S. (2009). Manual of clinical dialysis (2nd ed.). New York, NY:
Springer Science + Business Media, LLC.
5. Kallenbach, J. Z. (2012). Review of hemodialysis for nurses and dialysis
personnel (8th ed.). St. Louis, MO: Elsevier Mosby.
6. Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (Eds.).
(2010). Brunner and Suddarth’s textbook of medical-surgical nursing,
Volume 1 (12th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
7. Stam, L. E. (2009). 100 Questions & answers about kidney dialysis.
Sudbury, MA: Jones and Bartlett Publishers, LLC.
8. Shepard, L. (2011). Preparing your patient for hemodialysis. Nursing
Made Incredibly Easy! 9(6), 5-9.
doi: 10.1097/01.NME.0000406037.23361.77
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9. Castner, D. (2011). Management of patients on hemodialysis before,
during, and after hospitalization: Challenges and suggestions for
improvements. Nephrology Nursing Journal, 38(4), 319-330.
10. American Nephrology Nurses Association (ANNA). (2013). Hemodialysis
fact sheet. [Fact Sheet]. Retrieved from
http://www.annanurse.org/download/reference/practice/hemodialysisFactSh
eet.pdf
11. Khanna, R., Krediet, R. T. (Eds.). (2009). Nolph & Gokal’s textbook of
peritoneal dialysis (3rd ed.). New York, NY: Springer Science + Business
Media, LLC.
12. Mahon, A., Jenkins, K., & Burnapp, L. (Eds.). (2013). Oxford handbook
of renal nursing. Oxford, United Kingdom: Oxford University Press.
13. Burkhart, J. M. (2014, Jan. 7). Patient information: Peritoneal dialysis
(Beyond the basics). Retrieved from
http://www.uptodate.com/contents/peritoneal-dialysis-beyond-the-basics
14. Shapiro, M. H. (n.d.). Preventing catheter infections in peritoneal
dialysis. Retrieved from http://www.davita.com/treatment-options/homeperitoneal-dialysis/why-pd-first/preventing-catheter-infections-onperitoneal-dialysis/t/5515
15. Berns, J. S. (2012, Dec. 20). Patient information: Hemodialysis (Beyond
the basics). Retrieved from
http://www.uptodate.com/contents/hemodialysis-beyond-the-basics
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16. Dialysis Clinic, Inc. (2010). Hemodialysis access. Retrieved from
http://www.dciinc.org/hemodialysis_access.php
17. Woodrow, G., & Davies, S. (2010, July 30). Peritoneal dialysis in CKD.
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23. Thomas, N. (Ed.). (2013). Renal nursing (4th ed.). West Sussex, United
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