Objectives Kidney Function Diffusion

7/19/2013
Objectives
To gain a basic understanding of kidney function
To gain a basic understanding of the indications for acute
and chronic dialysis
To gain a basic understanding of hemodialysis (HD)-how
Hemodialysis
Peritoneal Dialysis
Continuous Renal Replacement Therapy
July 2013
Kim Windt BSN RN CNN
it works, treatment goals, and care of the pediatric patient
receiving hemodialysis.
To gain a basic understanding of peritoneal dialysis(PD)how it works, treatment goals, and care of the pediatric
patient receiving hemodialysis.
To gain a basic understanding of continuous renal
replacement therapy (CRRT)how it works, treatment
goals and care of the pediatric patient receiving CRRT
Kidney Function
Remove metabolic waste products from the blood
(urea, uric acid, creatinine)
Regulate vascular and extravascular volume by
controlling excretion of water
Regulate electrolyte balance
Regulate acid/base balance
Regulate BP through the production of renin
Kidney Function
Diffusion
Regulate bone marrow production of RBC’s by
synthesizing erythropoetin
Synthesize Vitamin D into active form
Secrete hormones that help regulate renal blood flow
Perform gluconeogenesis
Diffusion: The movement of solutes from a
higher to a lower solute concentration area.
Excrete drugs and toxins
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Solute Removal by Convection
Definition of Terms
Ultrafiltration-net removal of fluid from
patient
Clearance-removal of solutes from the blood
Dialyzer/Hemofilter/Artificial Kidney Convection: The movement of solutes with a waterflow, solvent drag”, e.g., the movement of
membrane-permeable solutes with ultrafiltered water.
Anatomy of a Hemofilter
blood in
Dialysate
out
Cross Section
hollow fiber
membrane
porous blood filter with blood compartment on
one side of the semipermeable membrane
and dialysate on the other
Dialysate Fluid
Bicarbonate based solution
Used to control electrolytes
Physician Prescribed
Components adjusted to meet patient needs
Pre-mixed solutions in sterile bags for PD
and CRRT
Combination of electrolyte acid solution,
Dialysate
in
Outside the Fiber
(effluent)
Inside the Fiber
bicarbonate solution and purified water for
HD
(blood)
blood out
Definition of Terms
Estimated Dry Weight (EDW) -Ideal
postdialysis weight after the removal of all or
most excess body fluid.
Goal of dialysis treatment is to achieve EDW
Accurate weights extremely important.
HD
Use of same scale, similar clothing preferred
1 Kg of weight =1liter of fluid
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Hemodialysis- Treatment Goals
Performed for acute and chronic renal failure
Hemodialysis
Blood tubing carries blood from the patient
Restores electrolyte and acid/base balance
access to the dialyzer and back to the patient
aided by a blood pump
Removes waste/toxins from the blood
In the dialyzer, waste products and excess fluid
Remove excess fluid from the patient – Goal
to achieve EDW
It can be used to clear the body from
overdoses or ingestion of toxic materials.
are removed from the blood by diffusion,
convection and osmosis.
Fluid removal also occurs as a result of the
pressure gradient exerted on the semipermeable membrane.
Hemodialysis
Peritoneal Dialysis
Continuous Renal Replacement Therapy
Acute Indications
Acute Renal Failure
Electrolyte and acid/base imbalances
Chronic Renal Failure - Initiation of treatment for
symptoms/unacceptable lab values
Metabolic Disorders
Hemolytic Uremic Syndrome (HUS)
Overdose/poisoning
Chronic Indications
Congenital Uropathy (PUV)
Congenital malformations of the kidney
(hypoplastic/dysplastic kidneys, ARPKD)
Nephrotic Syndrome
FSGS (Focal Segmental Glomerulosclerosis)
MPGN (Membranoproliferative
Glomeruonephritis)
Systemic Lupus Erythematous (SLE)
Hemolytic Uremic Syndrome (HUS)
Malignancy/Wilm’s Tumor
Severe chronic disease-Sickle Cell , HIV
nephropathy
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Stages of Chronic Kidney Disease
Stage
Description
GFR
(mls/min/1.73m2)
1
Kidney damage with normal or
increased GFR
>90
2
Kidney damage with mild decrease
GFR
60-89
3
Kidney damage with mild decrease
GFR
30-58
4
Severe ↓ GFR
15-29
5
Kidney Failure
<15 or dialysis
Frequency and Duration
Acute- as needed for removal of toxins
- usually daily for 3 days for ESRD
Chronic- usually 3 times a week for about 3-4
hours.
Duration may vary depending on size-small
children and infants will need less time per
treatment
Infants may require 4 or more treatments per
week if unable to tolerate fluid accumulation as
most/all nutrition is in liquid form.
Equipment
Hemodialysis machine. -Requires a water source
and Reverse Osmosis water purification system
Bicarbonate solution and Electrolyte solution – mix
with the purified water to create dialysate fluid
Dialyzer- varying sizes
One type of
Hemodialysis
machine
Interactive touch
screen to program
treatment parameters ,
integrated blood pump,
integrated heparin
syringe pump,
Disposable tubing set
with dialyzer.
Blood tubing- Adult, Pediatric, Infant
Bicarbonate
and Acid
(electrolyte)
solutions for
hemodialysis
Dialyzers
These solutions are
drawn up by the
hemodialysis
machine and mixed
with purified water to
create DIALYSATE
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Safe Extracorporeal Volume
The total priming volume of the tubing and filter
Dialyzers for
hemodialysis
is the “Extracorporeal Volume” (ECV)
To calculate a safe extracorporeal volume:
determine patient’s weight in kilograms (kg)
F3 is smallest dialyzer
available for infants –
priming volume is 29
mls.
80 mls./kg= estimated blood volume (EBV) in mls.
10 % of EBV is a safe extracorporeal volume
F200 – typical adult
dialyzer- priming
volume 113 mls
0.1 x EBV in mls.=safe extracorporeal volume
Infants may require blood prime if the ECV of
the smallest available equipment is greater
than their safe ECV as calculated by their
weight.
Access
Access
Double lumen Central Venous Catheter
Chronic– Cuffed tunneled CVC
Acute—femoral or internal jugular
Internal Jugular placement
preferred, but other sites
have been used if IJ is not
an option
NO SUBCLAVIAN PLACEMENT-stenosis or
occlusion may occur limiting future access
- stitched into place
- bedside placement by critical
care physician
- catheter stiff-kinks easily
Tunnelled Central
Venous Catheter
Examples of
Hemodialysis Catheters
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Tunneled Cuffed
Hemodialysis
Catheter
Catheter Care
Dressing changes per institution standard.
Ohio Collaborative recommends weekly dressing unless
loose, soiled or wet
if gauze under dressing and site not visible must change
every 48 hours
Prevention of infection critical
Do not allow catheter to get wet.
High dose heparin/alteplase/citrate instilled into
lumens to maintain patency
DO NOT FLUSH- Prior to use withdraw and discard
Minimize catheter accesses
Catheter Care
Review institution’s policy and procedures for
accessing a hemodialysis catheter.
Most institutions restrict use of HD catheters to avoid
complications of clotting and fibrin sheath formation
which can impede optimal catheter function
Access of catheter in emergent situations or to treat
infected lumens may be allowed
ALWAYS withdraw and discard anticoagulant
prior to flushing
Label catheter with lumen volumes and
anticoagulant instilled
TEGO connectors
A hemodialysis patient
may have a TEGO
connector on the end of
their catheter. It is a
yellow needleless cap
that is designed to
withstand high flow .(for
example the
hemodialysis blood
pump)
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Arterio-Venous Accesses- Fistula
Fistula- native artery surgically attached to native vein
Non-dominant arm preferred
Preferred access –decreased clotting
--decreased infection
--greatest longevity
--little daily care
Disadvantages --takes 6-8 weeks to mature
--requires suitable vessels
--requires 2 large needles ( 17-14g)
to be placed every treatment
AV Fistula with
Buttonhole sites
AV Fistula
AV Fistula
“Buttonhole” is a
technique in which the
exact site is used
repeatedly to create a
tract into the fistula so
that sharp needles are
no longer needed.
Blunt end needles are
used to access the
fistula once the tract is
healed decreasing the
discomfort for the
patient
Hemodialysis
patient with fistula
Accessed with 16
gauge needles
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Fistula needle
17 gauge 1
inch
Arterio-Venous Accesses-Graft
AV Graft
Graft- Synthetic material surgically placed
between an artery and a vein
Non-dominant arm preferred
Generally do not last as long as fistulae
Greater incidence of complications-especially
clotting
Also requires 2 large needles ( 14-17 g)
Advantage– can be used in 2-3 weeks
Loop AV Graft
Upper arm graft
AV Graft with
needles inserted
during HD
treatment
Upper arm graft accessed
with 16 gauge fistula needles
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Assessment and Care of AV
Accesses
Palpation of thrill at or near anastomosis
Auscultation of bruit
For newly placed access- assess suture line
for approximation and signs of infection
Note any swelling or bruising
No BP’s , IV’s or lab sticks in access extremity
No constrictive clothing
No activity that may constrict flow( for
example-hanging shopping bag over fistula
forearm)
Advantages of HD
Most efficient—highest rate of clearance
PRESERVATION OF BLOOD VESSELS IS
CRITICAL
Remember– pediatric patients will need some
form of access for life
Children who are transplanted will likely be on
some form of dialysis again at some point.
Pre- Dialysis patients need consideration also .
IV’s and lab sticks should be in the dominant
hand when possible (since access placement
will be targeted for non-dominant arm). Stick as
low as possible– avoid antecubital if possible.
Disadvantages of HD
Most stressful to cardiovascular system-may not be an
option for critically ill patients
Increased incidence of symptoms during
Can be done in shorter time than PD or CRRT
Precise fluid removal
treatment(cramping, hypotension)
Requires CVC or AV access
Primarily done in center only-disruptive to daily life
Strict fluid and diet restrictions as treatments are
generally only 3times /week
Does not require extensive pt/family involvement
Very small infants require blood prime which can
increase difficulty of obtaining matching donor kidney for
transplant
Nursing Considerations-Inpatient
Nursing Considerations - Inpatient
Meds-usual daily med okay to give pre-
dialysis(nephrocaps, phosphorus binders)
Some BP meds should be held until after dialysis
to avoid hypotension during treatment
Antibiotics should be given after dialysis as most
are removed during dialysis
Other Meds – may need special dosing ( ie
seizure med)
Labs–Often lab tests can be obtained by the
dialysis nurse when they enter the patient’s
access. This reduces needle sticks for the patient.
Notify Dialysis nurse of labs needed prior to treatment.
Some labs need to be drawn pre- treatment as
post treatment values will not be the true
equilibrated value. Others should be drawn posttreatment, such antibiotic levels.
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Nursing considerations- Inpatient
Fluids– Maintaining TFL reduces symptoms
during treatment as well as helping to maintain
desired BP and overall long term cardiovascular
stability.
Diet- Usually low potassium, low sodium, low
phosphorus
Daily weights/pre and post dialysis weights-
crucial in determining patient fluid status as
related to EDW
Peritoneal Dialysis
Utilizes the body’s richly vascular peritoneal
PD
Peritoneal Dialysis
During peritoneal dialysis, solutes (ie waste
products) are removed by diffusion.
Water is removed by osmosis.
Utrafiltration is controlled by the concentration of
dextrose in the dialysis solution (dialysate)
membrane as the semipermeable membrane or
“dialyzer”.
Warmed dialysis solution is instilled into the
peritoneal cavity and allowed to dwell there for a
determined period of time. Then the fluid is
drained from the patient. This is one exchange or
one cycle.
Peritoneal Dialysis – Treatment
Goals
Restores electrolyte and acid/base balance
Removes waste/toxins from the blood
Remove excess fluid from the patient – Goal to achieve
EDW
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Indications for Peritoneal
Dialysis
Medical Indications are the same as for chronic HD
Generally not used for acute indications as
clearance of toxins is less predictable and less rapid
with PD as compared with HD or CRRT
Is the therapy of choice for most pediatric patients
The peritoneal membrane in children is very large in
relation to their body surface area
Advantages of PD
Nightly PD allows for less restriction in diet-especially for
infants in whom nutrition depends mainly or solely on a
liquid diet
No need for vascular access which can be challenging in
infants and small children.
No need to blood prime hemodialysis tubing risking HLA
sensitization which increases difficulty in matching donor
kidneys
PD is performed at home
helpful for those who live a long distance from a pediatric dialysis
center
Allows for more normal lifestyle routines- regular school
attendance,
Disadvantages to PD
Contraindications to PD
Access requires surgical placement
Fluid removal is not precise
Chronic PD requires significant commitment from
family to perform nightly treatments. This may not be
feasible for all home situations.
Absolute
Omphalocele
Gastroschisis
Bladder extrophy
Diaphragmatic hernia
Obliterated peritoneal cavity
Peritoneal membrane failure
Relative
Inadequate living situation
for home dialysis
Lack of appropriate care
giver
Impending/recent major
abdominal surgery
Imminent LRD transplant
(within 6 m of dialysis
initiation)
PD Modalities
Acute Manual- Patient manually filled and drained
per MD order. Usually continuous. Done primarily
in the ICU setting and in the operating room
during PD catheter placement
CAPD- Abdomen is always full. Patient. Does 4-5
manual exchanges per day. Highest rate of
infection. Primarily an adult therapy.
CCPD- Use of automated cycler. Go on at night,
dialyze during sleep, cap off in the morning with
some fluid still in peritoneum.
IPD- Same as CCPD except left empty during the
day. Usually for infants or small children.
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Continuous Ambulatory Peritoneal
Dialysis (CAPD)
Equipment
For CCPD and IPD- Automated cycler that warms
and measures fluid as well as controls time and
number of programmed cycles
Disposable tubing
Premixed manufactured dialysate
Disposable tubing set with
attached dialysis solution bag,
Y set and drain bag
Regulates electrolyte and acid/base balance
Available in different dextrose concentrations to control
fluid removal by osmosis
Screen settings
NEWTON CYCLER
Premixed dialysate bags are
placed on heater tray/ scale
Communication screen with
touch keys to program
treatment parameters
Drain bag collects used
dialysate and ultrafiltrate
on hanging scale
PD ACCESS
PD catheters
Double or single cuffed, coiled or straight
tenckhoff PD catheter.
Placed surgically.
Inserted into peritoneal cavity, tunneled under
skin, exit onto abdomen.
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Care of the PD Catheter
SCOPE Recommendations
After placement, dressing change q 7 days unless
soiled, wet or loose
Sterile dressing change until site is healed
Keep catheter immobilized
Delay using catheter for 2 weeks if possible
Use of antibiotic cream at the site
What is the Nephrology
Collaborative or SCOPE ?
Part of the Quality Transformation Network w/in
Children’s Hospital Association (CHA)
Initially called Nephrology Peritonitis & Exit-Site
Infection Quality Collaborative
Now known as SCOPE - Standardizing Care to improve
Outcomes in Pediatric ESRD
Care of the PD Catheter
Pts. With drains, ostomies, GT, or diapers- must always
wear occlussive dressing.
May swim in chlorinated pool, ocean. NO LAKES, NO
PONDS, NO HOT TUBS, NO BATH TUBS. May shower
once healed.
Intact dressing
post op with capped
PD catheter
Exit Site Scoring System
0 points
Swelling
1 point
No
2 points
Exit only (<0.5cm)
Includes part
or entire tunnel
Crusting
No
<0.5 cm
>0.5 cm
Redness
No
<0.5 cm
>0.5 cm
Slight
Severe
Pain on pressure
Stabilizing & dressing the PD Catheter
Drainage
No
No
Serous
Purulent
*Infection should be assumed with a cumulative score > 4
Warady, Shaefer et al., Peritonitis Guidelines, PDI, 2000
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Nursing Considerations- Inpatient
Weight pre and post treatment
Redness & drainage
< or > 0.5 cm
Purulent drainage
VS pre and post treatment
Note color and quality of drained PD fluid
Cloudy fluid is indication of peritonitis
Blood Pressure can be related to volume.
Increased volume leads to hypertension
Dehydration leads to hypotension.
Maintain TFL
Maintain diet restrictions
For Chronic PD and HD Pediatric Patients
Growth and Nutrition
Children with renal disease have poor growth for
multiple reasons including: metabolic acidosis, renal
osteodystrophy, growth hormone resistance, anemia,
medications and caloric deficiency
Regular monitoring of Ht., Wt., HC essential
Many children require supplemental feeding – oral or
GT
Fluid limits may thwart nutritional efforts
Loss of appetite from renal disease may be
compounded by diet restrictions
Vomiting is common in infants further limiting caloric
intake
Development
Children on dialysis may not achieve developmental
milestones at the same rate as their peers
Studies show neurocognitive development is
delayed in children on dialysis
Frequent admissions to the hospital may delay
emotional and psychological development in children
on dialysis
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Medications
Phosphate binders:Calcium carbonate/Phoslo,TUMS
Renvela, Fosrenol: when taken with meals may
decrease the rate of bone loss that is common in
dialysis patients.
Renal Vitamins : Renalcaps, Nephrocaps,
Calcijex/Rocaltrol: The vitamin D analog for the
management of hypocalcemia.
Venofer (Iron Sucrose), Infed (Iron Dextran), Ferrous
sulfate : Iron supplementation for the treatment of
iron deficiency anemia.
Iron preparations must be given orally as they adhere
to surface of GT,NG
Medications
Medications
Antihypertensives: Amlodipine, Lisinopril, Atenolol
Injectable Medications:
Erythropoeitin/Epogen/Aranesp: promote red blood
cell production, decreasing or eliminating the need for
blood transfusions
Usually given intravenously in HD
Subcutaneously for PD
Human Growth Hormone: Long term treatment for
failure to grow
Daily injections at home
Preventative Care
Children should continue regular primary care visits
Medications that can be added to feeds
Calcium carbonate
Sodium chloride
Decanting of medications to be added to feeds
Kayexalate
Sevelemer
Fevers over 101.5 should be reported to the
Nephrology/Dialysis team if the child has a dialysis
access ( HD or PD catheter)
Consult with Dialysis Team regarding
OTC medications- some effect blood pressure
(Robitussin DM is acceptable)
Regular immunizations should be given on schedule
Influenza, Pneumococcal Pneumonia and Hepatitis B
vaccines are also recommended and will likely be
given in CKD clinic or Dialysis unit
Considerations at School
Children on Hemodialysis frequently miss school due to
HD schedule and may require extra academic help. PD
allows for better school attendance
Children on dialysis are at risk for infection as they are
immunocompromised
Children on dialysis usually require medication for
phosphorus binders with meals – they may need school
nurse assistance
Certain activities such as contact sports may need to be
limited to protect dialysis accesses
Adolescents on dialysis may have poor body image due
to stunted growth and maturity as well as other physical
changes such as dialysis accesses
Intensive Care Therapy
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Continuous Renal Replacement Therapy (CRRT)
CRRT
Blood tubing carries blood from the patient access to the
dialyzer and back to the patient aided by a blood pump
““Any extracorporeal blood purification therapy
intended to substitute for impaired renal function over
an extended period of time and applied for or aimed at
being applied for 24 hours/day.”
In the dialyzer, waste products and excess fluid are
removed from the blood by diffusion, convection and
osmosis.
Fluid removal also occurs as a result of the pressure
gradient exerted on the semi-permeable membrane.
Bellomo R., Ronco C., Mehta R, Nomenclature for Continuous Renal
Replacement Therapies, AJKD, Vol 28, No. 5, Suppl 3, Nov 1996
CRRT is very similar to HD- Flow rates are slower
and fluid shifts more gradual
Can be placed onto ECMO circuit if needed
Indications for CRRT
ICU setting only
Indications-fluid overload
-ARF, MSOF
- Sepsis
- Metabolic disorders
-Tumor lysis with chemo therapy
-Toxin removal/overdose
-CRF too unstable for routine tx.
CRRT Treatment Goals
Maintain fluid, electrolyte, acid/base balance
Prevent further damage to kidney tissue
Promote healing and total renal recovery
Allow other supportive measures; nutritional
support
Gentle continuous treatment
Equipment
Disposable tubing
Dialyzer/hemofilter (may come attached to tubing as
one continuous cartridge depending on type of
machine used)
Dialysate/Replacement Fluid Premixed solution to
control electrolyte and acid/base balance. Available
in different formulations with differing amounts of
potassium and bicarbonate
Blood pump and fluid pumps* Most units now using
a machine that has integrated pumps, fluid scales,
monitoring systems and interactive touch screens to
program treatment options and settings (Prismaflex)
Prismaflex
This is one type
of machine
used t0 deliver
CRRT.
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Dialysate/Replacement Fluid bags on
hanging scales of Prismflex machine used
for CRRT
Access for CRRT
Double lumen Central Venous Catheter
There are special tripe lumen catheters for specific
uses in CRRT
Non-tunnelled catheter - femoral or internal jugular
- stitched into place
- bedside placement by critical
care physician
- catheter stiff-kinks easily
Care of Access same as for HD catheter
CRRT Therapy Options
SCUF- Slow Continuous Ultrafiltration
CVVH – Continuous Venovenous Hemofiltration
CVVHD- Continuous Venovenous Hemodialysis
CVVHDF-Continuous Venovenous
Advantages of CRRT
Gentle, Well tolerated
Continuous treatment allows large volumes of fluid
for nutrition/meds
Precise fluid removal
Excellent solute removal when done continuously
Hemodiafiltration
Disadvantages of CRRT
Requires central venous access—same as acute
dialysis
Nursing Considerations
CRRT patients are 1:1 nursing ratio – must be
observed at all times
Slower solute removal than HD
Hourly ( or more frequent) vital signs
Continuous therapy-ICU only
Hourly intake and output assessment
Low volume- High Risk therapy- Requires
Hourly assessment of circuit pressure readings
extensive teaching and continued education and
review to maintain staff competency
Careful monitoring of intake and adjustment of fluid
removal rates
Frequent monitoring of electrolytes and other labs
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The goal for all
pediatric dialysis
patients is to move
towards renal
transplant
whenever
possible.
Achievement of this goal requires collaborative care from
practitioners in multiple different settings.
Resources
American Nephrology Nurses Association(ANNA) http://www.annanurse.org/
“Each
one of us can make a difference…
Together we make change.”
Barbara Mikulski
ANNA Pediatric Fact Sheets
http://www.annanurse.org/professional-development/practice/fact-sheets
Chadha, V. S. (2009). Dialysis- associated peritonitis in children. Pediatric Nephrology.
doi:10:1007/s00467-008-1113-6
Counts, C. S. (2008). Core Curriculum for Nephrology Nursing: Fifth Edition. Pitman, New
Jersey: Anthony J. Jannetti Inc.
National Kidney Foundation http://www.kidney.org/
Resources
Schmidt, C. Z. (2011, June 8). Peritoneal Dialysis Tailored to Pediatric Needs.
International Journal of Nephrology. doi:10.4061/2011/940267
Wong, C. W. (2013). Epidemiology, etiology and course of chronic kidney disease in children. (T.
Mattoo, Ed.) Retrieved March 1, 2013, from Up To Date:
Http://www.uptodate.com/contents/epidemiology-etiology-andcourse-of-chronic-kidneydisease. inchildren
Questions?
Wong, W. M. (2009, July). Care of the Neonate with Severe Renal Failure at Birth. Retrieved
March 1, 2013, from Newborn Services Clinical Guideline:
Http://www.adhb.govt.nz/newborn/Guidelines/Renal?Renalfailure.htm
Zaritsky, J. W. (2011, March). Peritoneal Dialysis in Infants and Young Children. Seminars in
Nephrology, 31(2), 213224.
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