dialysis: how does it work?how does it work? jassin m. jouria, md dr. jassin m. jouria is a medical...

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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 e-

module 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


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


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.


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. 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 c. arteriovenous (AV) fistula

d. catheter

Introduction


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.


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 end-

stage 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


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


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


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.


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


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


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.


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.


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


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


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 life-

threatening levels of certain chemicals.


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 end-

stage 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


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


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


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

http://www.dciinc.org/hemodialysis.php


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/home-

peritoneal-dialysis/why-pd-first/preventing-catheter-infections-on-

peritoneal-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

http://www.annanurse.org/download/reference/practice/hemodialysisFactSheet.pdfhttp://www.annanurse.org/download/reference/practice/hemodialysisFactSheet.pdfhttp://www.uptodate.com/contents/peritoneal-dialysis-beyond-the-basicshttp://www.davita.com/treatment-options/home-peritoneal-dialysis/why-pd-first/preventing-catheter-infections-on-peritoneal-dialysis/t/5515http://www.davita.com/treatment-options/home-peritoneal-dialysis/why-pd-first/preventing-catheter-infections-on-peritoneal-dialysis/t/5515http://www.davita.com/treatment-options/home-peritoneal-dialysis/why-pd-first/preventing-catheter-infections-on-peritoneal-dialysis/t/5515http://www.uptodate.com/contents/hemodialysis-beyond-the-basics


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.

Retrieved from http://www.renal.org/guidelines/modules/peritoneal-dialysis-

in-ckd#sthash.Ey8bMMHw.dpbs

18. Crabtree, J. H., Firanek, C. A., Piraino, B., Abu-Alfa, A. K., & Guest, S.

(2012). Care of the adult patient on peritoneal dialysis. [Fact Sheet].

Retrieved from

http://www.homebybaxter.com/Portals/0/Documents/AL06058C%20AFP%2

0Access%20Guide%20.pdf

19. Evans, L. M. (2012). Peritoneal dialysis: one unit’s response to

improving outcome and technique survival. Renal Society of Australasia

Journal, 8(3), 114-119.

20. Guterl, G. O. (2013, June 24). Nocturnal, in-home dialysis. Retrieved

from http://nursing.advanceweb.com/Features/Articles/Nocturnal-In-Home-

Dialysis.aspx

21. Arduino, M. J., Patel, P., Perz, J., Rainisch, K., Thompson, N., & Tumpey,

A. (2012). Infection prevention in dialysis settings. Retrieved from

http://www.cdc.gov/dialysis/clinician/CE/infection-prevent-outpatient-

hemo.html

22. Tennankore, K. K., Hingwala, J., Watson, D., Bargman, J. M., & Chan, C.

T. (2013). Attitudes and perceptions of nephrology nurses towards dialysis

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The information presented in this course is intended solely for the use of healthcare

professionals taking this course, for credit, from NurseCe4Less.com.

The information is designed to assist healthcare professionals, including nurses, in

addressing issues associated with healthcare.

http://kidneyschool.org/m01/http://kidneyschool.org/m08/http://kidney.niddk.nih.gov/kudiseases/pubs/yourkidneys/


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