DEFINITION

Chronic kidney disease (CKD)or chronic renal failure (CRF), as it was historically
termedis a term that encompasses all degrees of decreased renal function, from
damagedat risk through mild, moderate, and severe chronic kidney failure. CKD is a
worldwide public health problem. In the United States, there is a rising incidence and
prevalence of kidney failure, with poor outcomes and high cost.
The Kidney Disease Outcomes Quality Initiative (KDOQI) of the National Kidney
Foundation (NKF) established a definition and classification of CKD. These guidelines
have allowed better communication among physicians and have facilitated intervention
at the different stages of the disease.
The KDOQI defines CKD as either kidney damage or a decreased glomerular filtration
rate (GFR) of less than 60 mL/min/1.73 m 2 for 3 or more months. Whatever the
underlying etiology, once the loss of nephrons and reduction of functional renal mass
reaches a certain point, the remaining nephrons begin a process of irreversible sclerosis
that leads to a progressive decline in the GFR.
The different stages of CKD form a continuum. The KDOQI classification of the stages
of CKD is as follows:

Stage 1: Kidney damage with normal or increased GFR (>90 mL/min/1.73 m 2)

Stage 2: Mild reduction in GFR (60-89 mL/min/1.73 m 2)

Stage 3: Moderate reduction in GFR (30-59 mL/min/1.73 m 2)

Stage 4: Severe reduction in GFR (15-29 mL/min/1.73 m 2)

Stage 5: Kidney failure (GFR < 15 mL/min/1.73 m 2 or dialysis)

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In stage 1 and stage 2 CKD, reduced GFR alone does not clinch the diagnosis,
because the GFR may in fact be normal or borderline normal. Other markers of kidney
damage, including abnormalities in the composition of blood or urine or structural
abnormalities visualized by imaging studies, establish the diagnosis in such cases.
Hypertension is a frequent sign of CKD but should not by itself be considered a marker
of it, because elevated blood pressure is also common among people without CKD.
In an update of its CKD classification system, the National Kidney Foundation (NKF)
advised that GFR and albuminuria levels be used together, rather than separately, to
improve prognostic accuracy in the assessment of CKD. More specifically, the
guidelines recommended the inclusion of estimated GFR and albuminuria levels when
evaluating risks for overall mortality, cardiovascular disease, end-stage kidney failure,
acute kidney injury, and the progression of CKD. Referral to a kidney specialist was
recommended for patients with a very low GFR (< 15 mL/min/1.73 m) or very high
albuminuria (>300 mg/24 h)
Patients with stages 1-3 CKD are frequently asymptomatic. Clinical manifestations
resulting from low kidney function typically appear in stages 4-5.

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CAUSE
Causes of chronic kidney disease (CKD) include the following:

Diabetic kidney disease

Hypertension

Vascular disease

Glomerular disease (primary or secondary)

Cystic kidney diseases

Tubulointerstitial disease

Urinary tract obstruction or dysfunction

Recurrent kidney stone disease

Congenital (birth) defects of the kidney or bladder

Unrecovered acute kidney injury

Vascular diseases that can cause CKD include the following:

Renal artery stenosis

Cytoplasmic pattern antineutrophil cytoplasmic antibody (C-ANCA)positive and

perinuclear pattern antineutrophil cytoplasmic antibody (P-ANCA)positive
vasculitides

ANCA-negative vasculitides

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Atheroemboli

Hypertensive nephrosclerosis

Renal vein thrombosis

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DIAGNOSTIC TEST
To determine whether you have chronic kidney disease, you may need tests and
procedures such as:

Blood tests. Kidney function tests look for the level of waste products, such as
creatinine and urea, in your blood.

Urine tests. Analyzing a sample of your urine may reveal abnormalities that point
to chronic kidney failure and help identify the cause of chronic kidney disease.

Imaging tests. Your doctor may use ultrasound to assess your kidneys' structure
and size. Other imaging tests may be used in some cases.

Removing a sample of kidney tissue for testing. Your doctor may recommend
a kidney biopsy to remove a sample of kidney tissue. Kidney biopsy is often done
with local anesthesia using a long, thin needle that's inserted through your skin
and into your kidney. The biopsy sample is sent to a lab for testing to help
determine what's causing your kidney problem.

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SIGNS AND SYMPTOMS

Signs and symptoms of chronic kidney disease develop over time if kidney damage
progresses slowly. Signs and symptoms of kidney disease may include:

Nausea

Vomiting

Loss of appetite

Fatigue and weakness

Sleep problems

Changes in urine output

Decreased mental sharpness

Muscle twitches and cramps

Hiccups

Swelling of feet and ankles

Persistent itching

Chest pain, if fluid builds up around the lining of the heart

Shortness of breath, if fluid builds up in the lungs

High blood pressure (hypertension) that's difficult to control

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Signs and symptoms of kidney disease are often nonspecific, meaning they can also be
caused by other illnesses. And because your kidneys are highly adaptable and able to
compensate for lost function, signs and symptoms may not appear until irreversible
damage has occurred.

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PATHOPHYSIOLOGY
Predisposing
Factors:
A. Diagram
-

Precipitating Factors:

Hereditary
> 60 yrs. old
Autoimmune
Disorders

Decreased Renal blood

flow

Inc. Serum
Creatinine

DM
Hypertension
Diet
Smoking

Decreased glomerular
filtration
Inc. BUN

Dehydratio
n

Hypertrophy of remaining
nephrons

Polyuri
a

Loss of Na in
urine

Hyponatremi
a

Inability to concentrate
urine
Further loss of nephron
function

Dec.
Phosphate
excretion

Fail to produce
erythropoietin

Hyperphosphate
mia
Dec. Ca
absorption

Hypocalemi
a
Osteodystroph
y

Legends:
-

Laboratory results
Signs and
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Symptoms
Next flow

Dec.
excretion
of waste

Low RBC
count

Uremia

Anemi
a
Fatigue

Proteinuri
a

Shortnes
s of
breath

CNS
changes
Inc. waste
in blood

Coma

Death

Dec. Na
reabsorption
in tubule

Dec.
Potassium
excretion
Hyperkalemi
a

Water
retention
HTN

CHF
Edema
Dec. Hydrogen
excretion

Ammonia
Breath
Nausea
and
Dec.
appetite
Weight
Loss

Metabolic Acidosis

B. Narrative

Chronic Renal Failure is the gradual loss of kidney function. First of all, your kidneys
function as a filter to excrete wastes and excess fluids from your body that is in the form
of urine. When chronic kidney disease reaches an advanced stage, dangerous levels of
fluid, electrolytes and wastes can build up in your body.
Predisposing factors would include a.) Hereditary in which there is a history of your
father or mother having the same disease, b.) > 60 years old, in which older people
have low functioning kidneys, and c.) Autoimmune disorders such as lupus can damage
blood vessels and can make antibodies against kidney tissue.
Precipitating factors would include a.) Diabetes Mellitus and b.) Hypertension, which are
mostly the duo that contributes to having CRF. Both contributes in damaging the
kidneys when uncontrolled. C.) Diet, which is about high protein and cholesterol, can
later on lead to kidney damage and d.) Smoking can contribute to damages in blood
vessels which then increase risks for hypertension and later on, CRF.
In the early stages of chronic kidney disease, you may have few signs or symptoms.
There will be decreased in glomerular filtration as seen in lab results (Inc. BUN and
Creatinine). Later on, the body will compensate by means of working hard which then
contributes to its enlargement. Furthermore, there will be an inability of the kidney to
filtrate and malfunctioning in the absorption and excretion of minerals, which then
causes a number of problems such as hypocalcemia and edema. There is also failure to
produce Erythropoietin, a hormone released by the kidneys, which then contributes to
having Anemia, easy fatigability and shortness of breath. Chronic kidney disease may
not become apparent until your kidney function is significantly impaired. If untreated, it
can later on lead to coma, and death.

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COMPLICATION
Chronic kidney disease can affect almost every part of your body. Potential
complications may include:

Fluid retention, which could lead to swelling in your arms and legs, high blood
pressure, or fluid in your lungs (pulmonary edema)

A sudden rise in potassium levels in your blood (hyperkalemia), which could

impair your heart's ability to function and may be life-threatening

Heart and blood vessel disease (cardiovascular disease)

Weak bones and an increased risk of bone fractures

Anemia

Decreased sex drive or impotence

Damage to your central nervous system, which can cause difficulty

concentrating, personality changes or seizures

Decreased immune response, which makes you more vulnerable to infection

Pericarditis, an inflammation of the sac-like membrane that envelops your heart

(pericardium)

Pregnancy complications that carry risks for the mother and the developing fetus

Irreversible damage to your kidneys (end-stage kidney disease), eventually

requiring either dialysis or a kidney transplant for survival

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TREATMENT
A. Medical Management
Generic Name: Calcium Acetate
Brand Name: PhosLo
Classification: Mineral and electrolyte replacements/supplements
Indication: PO, IV:
-

Treatment and prevention of hypocalcaemia.

Control of hyperphosphatemia in end stage renal disease.

Action:
-

Essential for nervous, muscular, and skeletal systems. Maintain cell membrane
and capillary permeability. Act as an activator in the transmission of nerve
impulses and contraction of cardiac, skeletal and smooth muscle. Essential for
bone formation and blood coagulation. Therapeutic effects: Replacement of
calcium in deficiency states. Control of hyperphosphatemia in end stage renal
disease without promoting aluminum absorption.

Contraindication:
-

Hypercalcemia; Renal calculi; ventricular fibrillation.

Use cautiously in: Patients receiving digitalis glycosides; severe respiratory
Insufficiency; renal disease; cardiac disease.

Adverse Reaction/Side effects:

-

CNS: syncope (IV only), tingling;

CV: Cardiac arrest (IV only), arrhythmias, bradycardia.
GI: constipation, nausea, vomiting.
GU: calculi, hypercalciuria.
Local: phlebitis (IV only)

Dosage:
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PO (Adults): Hyperphosphatemia in end stage renal

disease Amount necessary to control serum phosphate
and calcium.

Nursing Interventions:
1. Observe patient for signs and symptoms of hypocalcemia (paresthesia, muscle
twitching, laryngospasm, colic, cardiac arrhythmias, Chvosteks or Trousseau
sign). Notify physician.
2. Monitor blood pressure, pulse, ECG frequently throughout parenteral therapy.
May cause vasodilation with resulting hypotension, bradycardia, arrythmias, and
cardiac arrest. Transient increases in blood pressure may occur during IV
administration, especially in geriatric patients or in patients with hypertension.
3. Laboratory Considerations: Monitor serum calcium or ionized calcium chloride,
sodium,

potassium,

magnesium,

albumin,

and

parathyroid

hormone

concentrations before and periodically during therapy for treatment of

hypocalcemia.
4. Do not administer concurrently with foods containing large amounts of oxalic acid
(spinach, rhubarb), phytic acid (cereals, brans), or phosphorous (milk or dairy
products).

Generic Name: Digoxin

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Brand Name: Lanoxin

Classification: antiarrhythmics, inotropic
Indication:
-

Treatment of CHF. Tachyarrhythmias: atrial fibrillation and atrial flutter.

Action:
-

Increases the force of myocardial contraction. Prolong refractory period of the

AV node. Decreases conduction through the SA and AV nodes. Therapeutic
Effects: increased cardiac output (positive inotropic effect) and slowing of the
heart rate (negative chronotropic effect).

Contraindication:
-

Hypersensitivity; uncontrolled ventricular arrhythmias;

AV block;
idiopathic hypertrophic subaortic stenosis.

Adverse Reactions/Side Effects:

-

CNS: fatigue, headache, weakness.

EENT: blurred vision, yellow or green vision.
GI: anorexia, nausea, vomiting, diarrhea.
Metab: electrolyte imbalances with acute digoxin toxicity.

Route/Dosage:
-

PO (Adults): 0.751.25 mg IV: 0.1250.25 mg IV.

Nursing Interventions:

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1. Monitor apical pulse for 1 min before administering; hold

dose if pulse < 60 in adult or < 90 in infant; retake pulse in
1 hr. If adult pulse remains < 60 or infant < 90, hold drug
and notify prescriber. Note any change from baseline
rhythm or rate.
2. Avoid IM injections, which may be very painful.
3. Follow diluting instructions carefully, and use diluted solution promptly.
4. Avoid giving with meals; this will delay absorption.
5. Have emergency equipment ready; have K+ salts, lidocaine, phenytoin, atropine,
and cardiac monitor readily available in case toxicity develops.
6. Weigh patient every other day with the same clothing and at the same time.
Record this on the calendar.
7. Advise patient to do not start taking any prescription or over-the-counter products
without talking to your health care provider. Some combinations may increase the
risk of digoxin toxicity and may put the patient at risk of adverse reactions.
8. Have regular medical checkups, which may include blood tests, to evaluate the
effects and dosage of this drug.
9. Report unusually slow pulse, irregular pulse, rapid weight gain, loss of appetite,
nausea, diarrhea, vomiting, blurred or yellow vision, unusual tiredness and
weakness, swelling of the ankles, legs or fingers, difficulty breathing.

Generic Name: Erythropoietin

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Brand Name: Epogen

Classifications: Hematopoietic
Indications:
-

This medication is a haematopoietic agent, prescribed for anemia in people with

chronic kidney failure. It helps in the formation of red blood cells by the bone
marrow.

Action:
-

Epogen stimulates erythropoiesis by the same mechanism as endogenous

erythropoietin.

Contraindication:
-

Contraindicated in patients with uncontrolled hypertension and hypersensitivity.

Caution should be exercised in patients with history of blood clotting problems,
cancer, sickle cell anemia, thalassemia, porphyria, blood clot events, heart
attack, infections, seizures, stroke, tumors, heart disease, any allergy, who are
taking other medications, during pregnancy and breastfeeding.

Adverse Reaction/Side Effects:

-

CV: Hypertension; vascular access thrombosis; DVT; thrombosis; MI, pulmonary

embolism.
CNS: Headache; dizziness; insomnia; depression; seizures. Derm: Pruritus, rash,

urticaria, erythema.
GI: nausea. Hemat: Leukopenia.
Musc: myalgia, bone pain, muscle spasm.
Resp: cough, URTI, respiratory tract infection.

Nursing Intervention:
1. Instruct patients to read the Medication Guide before starting therapy and at
regular intervals during treatment.
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2. Inform patients of the risks and benefits of epoetin alfa prior to treatment.
3. Inform patients with cancer that they must sign the patient-health care provider
acknowledgement before the start of each treatment course with epoetin alfa.
4. Inform patients of the increase risks of mortality, serious CV reactions,
thromboembolic reactions, stroke, and tumor progression.
5. Inform patients to undergo regular BP monitoring, adhere to prescribed
antihypertensive regimen, and follow dietary restrictions.
6. Inform patients to contact their health care provider for new-onset neurologic
symptoms or change in seizure frequency.
7. Inform patients of the need to have regular laboratory tests for Hgb.
8. Inform patients of the risks associated with benzyl alcohol in neonates, infants,
pregnant women, and breast-feeding mothers.
9. Instruct patients who self-administer epoetin alfa of the importance of following
instructions for use; dangers of reusing needles, syringes, or unused portions of
single-dose vials; proper disposal of syringes, needles, and unused vials, and of
the full container.

B. Surgical Management

1. Kidney Transplant
Indication
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The surgical implantation of a human kidney from a compatible donor in a

recipient. This procedure is performed as an intervention in irreversible kidney
failure. The kidney is surgically placed extraperitoneally in the iliac fossa. The
renal artery is anastomosed to the recipients hypogastric internal or external iliac
artery (Occasionally the aorta) and the renal vein to the recipients iliac vein.

Contraindications
-

Infection and active malignancy are the only absolute contraindications to

transplantation.
Some physical conditions markedly increase the risk for the client, however,
primarily long term immunosuppressive medications are necessary to avoid graft

rejection.
Clients with liver disease, psychological disorder, advanced atherosclerosis,
hypertension, respiratory disease, and gastrointestinal bleeding need particularly

consideration.
The primary factor limiting the number of transplantation done is the availability of
kidneys.

Complications
-

Graft rejection. The manifestations of renal transplant rejection include fever,

graft tenderness, at the site of the transplanted kidney, anemia, and malaise.
Urinary Tract Complications. Several complications may occur in the urinary
tract. Although it is rare, spontaneous rupture of the kidney may occur because of
rejection or ischemic damage. Leaking of the urine from the ureter-bladder

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anastomosis causes the development of a urinoma, which eventually puts

pressure on the kidney and ureter, reducing renal function. Long-term uremia and
steroid therapy may predispose the client to ureteral, bladder, or calicealcutaneous fistulae. Other urinary tract complications include ureteral, bladder, or
-

pelvic leaks, as well as obstruction, reflux, and lymphoceles.

Cardiopulmonary Complications. Hypertension occurs in 50% to 60% of adult
recipients and may be caused by renal artery stenosis, acute tubular necrosis,
acute and chronic graft rejection, hydronephrosis, hyperaldostorenism, largedose steroids, and cyclosporine. Cardiac dysrhythmias and heart failure may

result from fluid and electrolyte imbalances.

Pneumonia caused by bacteria and fungi is the most frequent respiratory
complication. Other respiratory problems include pulmonary edema, pulmonary

emboli, and reactivated tuberculosis.

Other complications. The reproductive problems associated with CRF commonly
disappear after transplantation. The incidence of gynecologic malignancies is
higher than in general population, with cervical cancer dominating. Successful
pregnancies has been completed after transplantation, although there is a risk for
both the fetus and the mother with a transplanted kidney.

Nursing Management Of The Surgical Client

-

Preoperative Care
o Before kidney transplantation, assess the clients understanding of the
procedure and follow-up regimen.
o Also, assess the clients ability to cope up with a complex medication
regimen after transplantation.
o The client needs to understand the transplantation and therapeutic regimen.

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o Preoperative preparation of both the living donor and the recipient includes all
aspects of general preoperative care.
-

Postoperative Care
o Assessment for renal transplant recipients is similar to that for most other
o

postoperative clients, with the exception of the focus on renal function.

Give particular attention to fluid balance, and carefully monitor intake and

output (every 30-60 minutes) and weight (daily).

o To monitor renal function and maintain electrolyte imbalance, obtain serial
laboratory determinations of haemoglobin, haematocrit, BUN (urea nitrogen),
o

creatinine, electrolytes, WBC count, and platelets.

Auscultate the kidney regularly to check for bruits, which might indicate

stenosis.
o Monitoring of vital signs is key, because even a slight temperature increase
may indicate an infection.

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C. Nursing Management

When a client is thought to have CRF, take a complete history and look closely to the
risk factors. Question the client about the past and present medications, diet and weight
changes, energy levels and unexplained fatigue, and the pattern of urinary elimination.

Assess the client for the multiple effects of CRF on all body systems, such as the
presence of cardiovascular or respiratory abnormalities, neurologic changes,

gastrointestinal problems, or skin changes.

Assess the clients understanding of CRF, the diagnostic tests that will be done,
and the possible treatment regimens. Evaluate the clients level of anxiety and
ability to cope. Involve the family in the assessment to determine their ability to

cope with the disease and treatments.

When the client begins peritoneal dialysis, the first assessment is infection.
Inspect the insertion site carefully for redness or other problems. Carefully
assess the drained dialysate or effluent for cloudiness, fibrin streaks, or blood.

Monitor the clients vital signs and weight closely.

If the client is undergoing hemodialysis, the first assessment is for the patency of
the venous access site. In a patent arteriovenous fistula or graft, a thrill or
vibrating sensation should be palpable and a bruit should be audible with the
stethoscope. It is vital that this site be assessed for possible occlusion or, if it is
an external site, for infection. Also ascertain the client understands of the access

site and its care.

Provide conservative therapy, as indicated.
Maintain strict fluid control; daily fluid intake should equal 500 ml (insensible
loss) plus the amount of the previous 24 hours urine output; daily weight; and

strict intake and output

Encourage intake of high biologic value protein foods such as eggs, dairy
products, and meats (causes positive nitrogen balance needed for growth and

healing)
Encourage high-calorie, low-protein, low-sodium, and low-potassium snacks
between meals.

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Encourage alternating activity with rest. Encourage independence as much as

possible.
Assess the client and familys response to chronic illness. Encourage therapeutic

conversations to help cope with chronic illness.

Provide symptomatic treatment.
Be prepared to identify and treat complications, which include hyperkalemia,
pericarditis, pericardial effusion, pericardial tamponade, hypertension, anemia,

and bone disease.

Administer prescribed medication, which may include ion exchange resin,
alkalizing agents, antibiotics, erythropoeitin, folic acid supplements, iron
supplements, phosphate-binding agents, calcium supplements, histamine

receptor antagonists, and proton-pump inhibitors.

Prepare the client for peritoneal dialysis, if indicated.
Provide proper shunt care, and assess for possible complications. (bleeding due
to heparinization, hypovolemia, hypotension due to excessive water removal,
dialysis disequilibrium syndrome (headache, confusion, and seizures) due to

rapid removal of urea from plasma.)

Provide postoperative care for any client who has undergone major surgery with
special attention to catheter patency and adequacy, intake and output, fluid

replacement, and protection from infection.

Monitor for signs and symptoms of complications such as:
1. Graft rejection (fever, elevated white blood cell count, electrolyte abnormalities,
abnormal renogram)
2. Infection stemming from immunosuppressive therapy (sepsis pneumonia,
wound infection, and urinary tract infection)

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DAVAO MEDICAL SCHOOL FOUNDATION, Inc.

Medical School Drive, Bajada, Davao City
College of Nursing
NURSING CARE PLAN

NURSING DIAGNOSIS

Altered nutrition less than

body requirement r/t
anorexia and malnutrition
secondary to renal failure.

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GOAL OF CARE

Demonstrate behaviors,
lifestyle changes to regain
and maintain an
appropriate weight.
Normalize Vital signs.
Have a good appetite.
Understand the importance
of nutritious food (Veggies,
Fruits.)
Have a balance intake and
output.
Comply with the treatment
regimen.

NURSING INTERVENTIONS

EVALUATION

Assess general appearance

In my 8 hours span of care ,
Goal partially met;
and monitor vital signs.
Assist in developing individual
Patient demonstrated
regimen.
Provide diet modification as
behavior to regain and
indicated.
maintain appropriate
Encouraged the patient to avoid
weight.
sodium rich food.
Patients have slightly
Promote relaxing environment
good appetite.
conducive for resting.
Patient understands
Proved patients safety.
the importance of
Encouraged the patient to
nutritious intake.
change position every 2 hours.
Had a balanced intake
Encourage to do passive range
and output.
of motion exercise.
Patient comply with the
Regulate above IVF as
treatment.
ordered.
Administer medication. As
ordered.

24 | P a g e

DAVAO MEDICAL SCHOOL FOUNDATION, Inc.

Medical School Drive, Bajada, Davao City
College of Nursing
NURSING CARE PLAN

NURSING DIAGNOSIS

Impaired urinary
elimination r/t loss of
kidney functions
secondary to renal failure.

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GOAL OF CARE

Normalized Vital signs.

Verbalized understanding
of condition.
Participate in measures to
correct/ compensate for
defects

NURSING INTERVENTIONS

Monitor and record vital signs.

Review laboratory test for
changes in renal function.
Determine clients pattern of
elimination.
Palpate the patients bladder.
Investigate pain, noting
location.
Note condition of skin and
mucous membrane.
Note urine color, consistency
and amount.
Observe for signs of infection.
Encouraged to verbalized
feelings/concerns.
Emphasized the need to
adhere with prescribed diet.
Emphasize the importance of
having a good hygiene.
Administer medication, as
ordered.

EVALUATION

In my 8 hours span of care,

Goal partially met;
Patient participates in
complying treatment
regimen.
Patient verbalizes
understanding of
condition.

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DAVAO MEDICAL SCHOOL FOUNDATION, Inc.

Medical School Drive, Bajada, Davao City
College of Nursing
NURSING CARE PLAN

NURSING DIAGNOSIS

Risk for impaired skin

Integrity r/t reduced
activity/immobility
secondary to renal failure..

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GOAL OF CARE

Normalize Vital signs.

Perform ADL without
assistance.
Ambulate properly.
Participate in the
treatment.
Have a good skin
condition.
Have balanced intake and
output.

NURSING INTERVENTIONS

Check and record patients vital

signs.
Encourage patient to comply
with treatment regimen.
Monitor patients fluid intake
and hydration of skin.
Change patient position
frequently.
Provide soothing skin care
(apply ointments or creams.)
Advised patient to report id
experience itching.
Advised patient to use cool,
moist compress to apply
pressure ( Rather than scratch)
Administer medication as
ordered.

EVALUATION

In my 8 hours span of care,

Goal partially met;
Patients perform ADL
with minimal
assistance.
Assess for patients
skin; Intact skin noted.
Patient demonstrate
behavior/ techniques to
prevent skin
breakdown.

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BIBLIOGRAPHY
Books

Medical-surgical 2010 chapter 38 Management of Clients with Renal Failure

pg.963

E-sources:

http://emedicine.medscape.com/article/238798-overview#a0101
http://www.mayoclinic.org/diseases-conditions/kidney-

disease/basics/complications/con-20026778
http://www.mayoclinic.org/diseases-conditions/kidney-

disease/basics/symptoms/con-20026778
http://www.mayoclinic.org/diseases-conditions/kidney-disease/basics/tests-

diagnosis/con-20026778
http://emedicine.medscape.com/article/238798-overview#aw2aab6b2b3
http://www.nursing-nurse.com/medical-and-nursing-management-of-chronicrenal-failure-422/2/

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