Renal Disease and Renal Transplantation - PowerPoint PPT Presentation

Loading...

PPT – Renal Disease and Renal Transplantation PowerPoint presentation | free to download - id: 41e563-N2QyY



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Renal Disease and Renal Transplantation

Description:

Renal Disease and Renal Transplantation Jessica Weber, MSN, RN, ACNS-BC, CCTN Clinical Nurse Specialist Transplant and General Surgery University of Wisconsin ... – PowerPoint PPT presentation

Number of Views:468
Avg rating:3.0/5.0
Slides: 70
Provided by: Jessica271
Learn more at: http://macaapc.org
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Renal Disease and Renal Transplantation


1
Renal Disease and Renal Transplantation
  • Jessica Weber, MSN, RN, ACNS-BC, CCTN
  • Clinical Nurse Specialist
  • Transplant and General Surgery
  • University of Wisconsin Hospital and Clinics

2
Objectives
  • Anatomy/Physiology of the renal system
  • Acute kidney injury
  • Chronic kidney failure
  • Causes of End Stage Renal Disease (ESRD)
  • Treatments for ESRD
  • The pre-transplant process
  • Transplant surgical procedure
  • Immunosuppression
  • Complications of transplantation

3
Anatomy of the Renal System
  • Kidneys
  • Nephrons-functional
  • unit of kidney responsible
  • for making urine
  • Ureters
  • fibromusular tube that
  • connects each kidney
  • to the bladder
  • Bladder
  • muscular, hollow sac that
  • holds urine
  • Urethra
  • arises from bladder and empties urine. The
    urinary sphincter controls the initiation of
    urination

4
Physiology of the Renal System
  • Vascular
  • Blood from the renal arteries is delivered to the
    glomeruli.
  • Glomeruli
  • Ultrafiltration occurs at the glomeruli
  • forming an ultrafiltrate, which
  • subsequently
  • flows into the renal tubules.
  • Renal tubules
  • Reabsorption and secretion of solute
  • and/or water from the ultrafiltrate
  • occurs within the tubules.
  • Urinary tract
  • The final tubular fluid, the urine, leaves the
    kidney, draining sequentially into the renal
    pelvis, ureter, and bladder, from which it is
    excreted through the urethra.

5
Symptoms
  • Renal
  • Oliguria
  • Dark/bloody urine output
  • General
  • Flank pain
  • Weakness
  • Hematologic
  • Anemia
  • Bleeding
  • Neurologic
  • Mental status changes
  • Lethargy
  • Gastrointestinal
  • Anorexia
  • Nausea/Vomiting
  • Cardiovascular
  • Peripheral edema
  • Hypertension
  • CHF
  • Respiratory
  • Dyspnea
  • Crackles
  • Pulmonary edema

6
Labs in Renal Disease
  • Glomerular Filtration Rate (GFR)
  • Measures the degree of renal impairment by
    measuring the filtering capacity of the kidneys.
  • Predicts progression of kidney disease and risk
    of complications of chronic kidney disease
  • Cannot be measured directly
  • Abreviated MDRD uses creatinine, age, sex, and
    race
  • Cockcroft-Gault uses creatinine, age, sex and
    lean body weight
  • Creatinine
  • serum creatinine concentration alone should not
    be used to assess the level of kidney function
  • Blood Urea Nitrogen (BUN)
  • Potassium
  • Proteinuria
  • First check on urinalysis
  • If urinalysis is postive for albumin then a urine
    proteincreatinine ratio will be checked

7
Acute Kidney Injury (Previously known as Acute
Renal Failure)
  • An abrupt reduction in kidney function measured
    by a rapid decline in glomerular filtration rate.
    An acute decline in kidney function is secondary
    to an injury that leads to functional or
    structural changes in the kidney.
  • AKI results in
  • Impairment of nitrogenous waste product excretion
  • Loss of water and electrolyte regulation
  • Loss of acid-base regulation

8
Acute Kidney Injury
  • Prerenal-occurs before damage to the kidney
    occurs
  • Hypovolemia
  • Decreased cardiac output
  • Decreased peripheral vascular resistance
  • Renal vascular obstruction
  • Intrinsic/Intrarenal-occurs within the kidney and
    damage is usually irreversible (ATN)
  • Nephrotoxic
  • Acute glomerulonephritis
  • Postrenal (Obstructive)-obstruction of structures
    leaving the kidneys
  • Urinary tract obstruction
  • Bladder/Prostate cancer

9
Chronic Kidney Disease Definition
  • GFR lt 60 mL/min/1.73 m2 for gt 3 months
  • OR
  • Kidney damage (pathologic abnormalities or
    markers of damage, including abnormalities in
    blood or urine tests or imaging studies) for gt 3
    months

10
Chronic Kidney Disease
  • 26 million American adults have CKD
  • Early detection can help prevent the progression
    of kidney disease to kidney failure.
  • Heart disease is the major cause of death for all
    people with CKD.
  • Hypertension causes CKD and CKD causes
    hypertension.
  • African Americans, Hispanics, Pacific Islanders,
    Native Americans and Seniors are at increased
    risk.

11
CKD Risk Factors
  • Diabetes, HTN, Autoimmune diseases
  • Infections
  • Obstructions
  • AKI
  • Certain medications
  • Age
  • Ethnic minority status
  • Low income/education
  • Environmental exposures

12
Stages of Chronic Kidney Disease
  • Stage 1
  • normal GFR and persistent albuminuria
  • Stage 2
  • GFR 60 to 89 and persistent albuminuria
  • Stage 3
  • GFR 30 to 59
  • Stage 4
  • GFR 15 to 29
  • Stage 5
  • GFR of less than 15 or end-stage renal disease
    (when HD is initiated)

13
Prevalence of Co morbidities
NHANES 20012008 participants age 20 older.
14
Co morbidities
15
Mortality Rates
NHANES 19992004 participants age 20 older.
16
Mortality rates in Medicare patients, by CKD
diagnosis code
January 1, 2009 point prevalent patients age 66
older. Adj age/gender/race/prior
hospitalization/comorbidities. Ref 2009 patients.
17
End-Stage Renal Disease
  • End-stage renal disease (ESRD)
  • administrative term in the United States, based
    on the conditions for payment for health care by
    the Medicare ESRD Program, specifically the level
    of GFR and the occurrence of signs and symptoms
    of kidney failure necessitating initiation of
    treatment by replacement therapy.
  • ESRD includes patients treated by dialysis or
    transplantation, irrespective of the level of
    GFR.
  • Kidney failure
  • (1) a level of GFR to lt15 mL/min/1.73 m2, which
    is accompanied in most cases by signs and
    symptoms of uremia
  • (2) a need for initiation of kidney replacement
    therapy (dialysis or transplantation) for
    treatment for complications of decreased GFR,
    which would otherwise increase the risk of
    mortality and morbidity.

18
Causes of End Stage Renal Disease
  • Diabetes
  • Hypertension
  • Hereditary
  • Polycystic Kidney Disease (PCKD)
  • Alports Disease
  • Auto-Immune
  • Primary Glomerulonephritis
  • Systemic Lupus Erythematosus (SLE)
  • Wegeners Granulomatosis
  • Focal Segmental Glomerulonephrosclerosis (FSGS)
  • Renal Cell Carcinoma (RCC)
  • Renal Artery Stenosis / Renal Vein Thrombosis
  • Urologic
  • Reflux Nephropathy
  • Stones
  • Frequent chronic UTIs

19
Treatment Options for ESRD
  • Hemodialysis
  • Peritoneal Dialysis
  • Renal Transplantation
  • Living donor
  • Deceased donor

20
INITIATION OF DIALYSIS
  • Patients who reach CKD stage 4 should receive
    timely education about kidney failure and options
    for its treatment, including kidney
    transplantation, PD, HD in the home or in-center,
    and conservative treatment.
  • Estimation of GFR should guide decision making
    regarding dialysis therapy initiation.
  • When patients reach stage 5 CKD nephrologists
    should evaluate the benefits, risks, and
    disadvantages of beginning kidney replacement
    therapy.

21
Clinical Indications for Dialysis
  • Uremia (N/V, anorexia, confusion)
  • Fluid overload (pulmonary edema)
  • Persistent metabolic disturbances
  • Hyperkalemia (gt6.0)
  • Metabolic acidosis (Bicarb lt16)
  • Hypercalcemia/hypocalcemia
  • Hyperphosphatemia
  • Pericarditis
  • Hypertension that is not responsive to
    medications
  • Anemia

22
Hemodialysis
  • Removes accumulated solute from a patient who has
    total or near-total loss of kidney function.
  • Diffusion of solute from the blood into a
    physiological salt solution
  • (dialysate) that is separated from
  • the blood by a thin
  • semipermeable membrane,
  • the major component of the
  • dialyzer.
  • Access
  • HD catheter
  • AV Fistula
  • Graft

23
Dialysis Access
  • In patients with CKD stage 4 or 5, forearm and
    upper-arm veins suitable for placement of
    vascular access should not be used for
    venipuncture or for the placement of intravenous
    (IV) catheters, subclavian catheters, or
    peripherally inserted central catheter lines
    (PICCs).
  • Patients should have a functional permanent
    access at the initiation of dialysis therapy.
  • A fistula should be placed at least 6 months
    before the anticipated start of HD treatments.
    This timing allows for access evaluation and
    additional time for revision to ensure a working
    fistula is available at initiation of dialysis
    therapy.
  • A graft should, in most cases, be placed at least
    3 to 6 weeks before the anticipated start of HD
    therapy. Some newer graft materials may be
    cannulated immediately after placement.
  • A peritoneal dialysis (PD) catheter ideally
    should be placed at least 2 weeks before the
    anticipated start of dialysis treatments. A
    backup HD access does not need to be placed in
    most patients. A PD catheter may be used as a
    bridge for a fistula in appropriate patients.

24
(No Transcript)
25
Peritoneal Dialysis
  • Continuous Ambulatory PD
  • patient performs manual exchanges 4-5 times/day
  • Continuous Cycling PD
  • Patient hooks up to a machine at night and
    exchanges are carried out automatically while the
    patient sleeps
  • Home based therapy
  • with little equipment set
  • up time
  • 12 of patients
  • choose PD
  • Contraindicated in
  • patients with adhesions,
  • fibrosis, or malignancy
  • in peritoneum

26
Renal Transplantation
  • In the US 91,015
  • people are waiting
  • for a kidney
  • transplant
  • In the US to date 316,493 kidney transplants have
  • been done

27
Transplantation Facts
  • Fact An open casket funeral is possible for
    organ, eye and tissue donors. Through the entire
    donation process the body is treated with care,
    respect and dignity.
  • Fact There is no cost to the donor or their
    family for organ or tissue donation.
  • Fact Signing a donor card and a driver's license
    with an "organ donor" designation may not satisfy
    your state's requirements to become a donor. Be
    certain to take the necessary steps to be a donor
    and ensure that your family understands your
    wishes.

28
Transplantation Facts
  • Fact Anyone can be a potential donor regardless
    of age, race, or medical history.
  • Fact All major religions in the United States
    support organ, eye and tissue donation and see it
    as the final act of love and generosity toward
    others.
  • Fact If you are sick or injured and admitted to
    the hospital, the number one priority is to save
    your life. Organ, eye and tissue donation can
    only be considered after you are deceased.
  • Fact When you are on the waiting list for an
    organ, what really counts is the severity of your
    illness, time spent waiting, blood type, and
    other important medical information, not your
    financial status or celebrity status.

29
WWW.YESIWILLWISCONSIN.COM
  • Having your name included in the Wisconsin donor
    registry means that you have authorized the gift
    of your organs, tissues, and eyes upon your
    death. Registering indicates legal consent for
    donation.
  • If you are at least 18 years old or an
    emancipated minor, your decision may not be
    overridden by your family or any other person. If
    you are an unemancipated minor, only your parents
    can override your decision.
  • There are over 40 state donor registries now in
    operation
  • Wisconsins registry is maintained by the
    Wisconsin Department of Health Services in
    cooperation with the Wisconsin Department of
    Transportation.

30
Pre-Transplant Process
  • Referral for transplant is made by PCP,
    Nephrologist/Hepatologist, and/or patient
  • The Pre-Transplant Coordinator calls patient to
    Pre-Screen
  • obtain medical/surgical history
  • recommends necessary/further testing
  • Patient must check w/insurance to determine what
    transplant centers are approved for service.

31
Pre transplant Testing
  • All potential transplant recipients
  • General H P, dialysis notes, labs, current
    meds
  • Chest Xray
  • Cardiac testing EKG, stress test, and/or cath
  • Dental clearance
  • Colonoscopy (over 50 years old)
  • ABO verification, tissue typing, crossmatching
  • Women
  • Pap pelvic
  • Mammogram (over 40 years old) Men over 50
    Cardiac testing and colonoscopy
  • Men
  • PSA (over 50 years old)
  • Diabetic
  • Cardiac catheterization (regardless of age)
  • All done prior to scheduling appointment for
    evaluation

32
Kidney Evaluation Day
  • Patient meets with
  • Financial Counselor
  • Social Worker
  • Transplant Coordinator
  • Transplant Physician/Surgeon
  • Dietician

33
Contraindications to Transplantation
  • Current alcohol and drug abuse
  • Cancer
  • Obesity
  • Age
  • HIV
  • Severe cardio/pulmonary/vascular disease
  • Multiple comorbidities

34
United Network for Organ Sharing (UNOS)
  • The private, non-profit organization that manages
    the nation's organ transplant system under
    contract with the federal government.
  • UNOS is involved in
  • Managing the national transplant waiting list,
    matching donors to recipients 24 hours a day, 365
    days a year
  • Maintaining the database that contains all organ
    transplant data for every transplant event that
    occurs in the U.S.
  • Bringing together members to develop policies
    that make the best use of the limited supply of
    organs and give all patients a fair chance at
    receiving the organ they need, regardless of age,
    sex, ethnicity, religion, lifestyle or
    financial/social status. Monitoring every organ
    match to ensure organ allocation policies are
    followed.
  • Providing assistance to patients, family members
    and friends.
  • Educating transplant professionals about their
    important role in the donation and transplant
    processes.
  • Educating the public about the importance of
    organ donation

35
Kidney Listing Process
  • Listed per
  • Blood type only
  • 6 HLA antigens
  • PRA/identified antibodies
  • Must have GFR gt15 or Dialysis
  • Average UW Transplant List Wait Time
  • Kidneys
  • Average 3.5 years
  • Blood Types
  • A 1-1.5 years
  • B 2-2.5 years
  • O 2.5 3 years
  • AB 6 months

36
Where am I on the list?
  • Point system
  • Patient receives points for the following
  • Calendar days on list
  • Antigen matching with potential donor
  • Age (pediatric patients)
  • Highly sensitized/High PRA patients
  • Patients place changes from day to day, from
    donor to donor

37
Once listed
  • Patient Responsibilities
  • Monthly blood samples
  • Update demographic/medical status
  • Center Responsibilities
  • Annual chart review/updated records
  • Every 2 year re-evaluation

38
Why might we not call the first person on the
list?
  • Positive X-match
  • Pt not medically suitable for transplant
  • Age discrepancy
  • Weight / Size discrepancy
  • Length of ischemia time due to pt travel
  • Pt refused
  • Local nephrologist refused

39
Deceased Donor Types
  • Brain Death
  • Determined by a neurologist
  • Patient is breathing, on a ventilator at time of
    donation.
  • Declared Cardiac Death (DCD)
  • Ventilator support is withdrawn in the OR.
  • Determined by the patients critical care doctor.
  • Due to lack of blood flow, some ramifications.

40
What is a CDC High Risk Donor?
  • As defined by the Centers for Disease Control and
    Prevention (CDC)
  • Regardless of their HIV antibody test results,
    persons who meet any of the criteria listed below
    should be excluded from donation of organs or
    tissues, unless the risk to the recipient of not
    performing the transplant is deemed to be greater
    than the risk of HIV transmission and disease.
    In such a case, informed consent regarding the
    possibility of HIV transmission should be
    obtained from the recipient.

41
Post-Transplant Follow-up for CDC High Risk Donor
  • Prior to the OR HBV, HCV, HIV serology
  • 1 Month HBV, HCV, HIV serology PCR testing
    along with transplant physician clinic visit
  • 3-6 Months Repeat HBV, HCV, HIV serology PCR

42
Extended Criteria Donors (ECD)
  • Over the age of 60 years
  • Over the age of 50 years with two of the
    following
  • a history of hypertension,
  • a terminal serum creatinine greater than or equal
    to 1.5 mg/dl,
  • death resulting from a cerebral vascular accident
    (stroke).

43
Surgical Technique
  • Donor kidney anatomy
  • Preservation of donor kidney
  • Location and anastomosis
  • Length of surgery

44
Surgical Technique
45
Surgical Technique
46
Blood Flow Complications-Thrombosis
  • Definition blood clot in an artery or vein
  • Signs
  • Kidney-sudden decrease in UO Increased
    creatinine, hematuria.
  • Diagnosis US, Scan
  • Treatment OR, Anticoagulation

47
Blood Flow Complications-Hematoma
  • Definition collection of blood in abdomen
  • Signs hypotension/tachycardia, increased pain,
    decreased Hct
  • Diagnosis CT
  • Treatment OR, RBC infusions

48
Surgical Complications-Anastomotic Leak
  • Definition tear at connection of donor and
    recipient anatomy
  • Signs
  • Kidney-increased creatinine, decreased UO, yellow
    fluid drng from incision (with higher creatinine
    than serum), increased pain
  • Diagnosis-US, Scan, CT
  • Treatment foley/nephrostomy tube

49
Surgical Complications-Obstruction
  • Obstruction
  • Definition blockage of flow
  • Signs
  • Kidney-increased creatinine, decreased UO,
    hydronephrosis
  • Diagnosis-US, Scan,
  • Treatment based on time of event in postop period

50
Immunosuppression
  • Induction
  • Maintenance
  • Rejection Treatment

51
Induction
  • Basiliximab (Simulect)
  • Monoclonal
  • Binds T cell receptor for interleukin-2
  • IV infusion intraop and on POD 4
  • Few GI side effects
  • Antithymocyte Globulin (Thymoglobulin)
  • Polyclonal
  • T cell depletion
  • IV infusion intraop and up to 10 days postop
  • Premeds
  • Chills, fever, pulmonary edema, thrombocytopenia,
    leukopenia

52
Maintenance Immunosuppression
  • Prednisone
  • First major immunosuppressant
  • Now try to supplement with others and decrease
    dose
  • Steroid-free protocols
  • PO and IV
  • Inhibits T cell production
  • Many side effects
  • Hyperglycemia
  • Hypertension
  • Weight gain and swelling
  • Mood changes
  • Osteoporosis
  • Dyslipidemia
  • Gastric Ulcers

53
Maintenance Immunosuppression
  • Mycophenolate Mofetil (Cellcept,Myfortic)
  • Inhibits proliferation of B and T cells
  • PO and IV
  • Gl side effects-less with Myfortic
  • Leukopenia, Thrombocytopenia, Anemia
  • Azathioprine (Imuran)
  • Inhibits proliferation of B and T cells
  • PO
  • Leukopenia, Thrombocytopenia
  • Hepatotoxicity, Infection, Alopecia
  • Sirolimus (Rapamune)
  • Inhibits T cell activation
  • PO
  • Decreased healing, DGF, Thrombocytopenia

54
Maintenance Immunosuppression- Calcineurin
Inhibitors
  • Tacrolimus (Prograf, FK-506)
  • Inhibit production and release of IL-2 and T-cell
    activation and proliferation
  • PO and IV
  • Take without food
  • More potent than cyclosporine
  • Drug interactions-metabolized by cytochrome P450
    in the liver
  • Side effects
  • Nephrotoxicity
  • Hyperkalemia, hypomagnesaemia
  • Hypertension, hyperlipidemia
  • Hyperglycemia

55
Maintenance Immunosuppression- Calcineurin
Inhibitors
  • Cyclosporine (Neoral, Gengraf, Sandimmune)
  • Inhibit production and release of IL-2 and T-cell
    activation and proliferation
  • PO and IV
  • Take with food
  • Drug interactions-metabolized by cytochrome P450
    in the liver
  • Side effects
  • Nephrotoxicity and hepatotoxicity
  • Hypertension
  • Hyperkalemia, hypomagnesaemia
  • Hyperglycemia
  • Tremors

56
Rejection
  • Hyperacute Rejection
  • Acute Cellular Rejection
  • Antibody Mediated Rejection
  • Chronic Rejection

57
Hyperacute Rejection
  • Preformed antibodies to ABO blood group antigens
    or HLA antigens are present
  • Very rare due to crossmatching
  • Occurs within hours of revascularization
  • Must remove kidney

58
Acute Cellular Rejection
  • T cell mediated injury
  • Most common type of rejection
  • Most commonly occurs within first 3 months after
    transplant
  • Mild to Severe
  • Increases risk for chronic rejection
  • Diagnosed by biopsy
  • Almost always reversible
  • Treatment
  • Corticosteroids
  • Thymoglobulin

59
Antibody Mediated (Humoral) Rejection
  • Antibodies injure organ
  • Positive C4D stain on biopsy
  • Monitor levels of donor specific antibodies
  • Treatment
  • May not respond to steroid treatment
  • Rituximab
  • Monoclonal antibody
  • Fever, chills
  • Plasmapheresis
  • Immunoglobulin

60
Infection
  • Solid organ transplant patients are at high risk
    for infections
  • Prophylaxis
  • Pretransplant immunizations
  • Peritransplant antibiotics
  • Posttransplant TMP/sulfa, (val)ganciclovir,
    (val)acyclovir, clotrimazole

61
Bacterial Infections-PCP
  • Mostly want to prevent against Pneumocystis
    Carinii Pneumonia (PCP)
  • Symptoms of PCP
  • Fever, dyspnea, cough
  • Elevated WBCs
  • Patchy interstitial infiltrates on chest X-ray
  • Prophylaxis and Treatment
  • TMP/Sulfa (Bactrim)-usually once daily for 1 year
  • Pentamidine inhalation-once monthly for 6 months

62
Viral Infections-CMV
  • Cytalomegalovirus (CMV)-most common opportunistic
    infection in transplant patients
  • CMV infection vs CMV disease
  • CMV infection detection of virus via molecular
    techniques or changes in serology
  • CMV disease requires clinical signs and symptoms
  • Fever
  • Leukopenia/neutropenia
  • Organ involvement
  • Diagnosis
  • CMV PCR
  • Biopsy

63
Viral Infections-CMV
  • Risk Factors
  • CMV negative recipients from a positive donor
  • Patients who received Thymo or OK-T3
  • Prophylaxis
  • Dosed based on risk factors
  • 3-6 months
  • Valganciclovir
  • Acyclovir
  • Treatment
  • IV Ganciclovir- 5mg/kg IV Q12H
  • Valganciclovir 900mg PO BID

64
Fungal Infections-Thrush
  • Fungal infection of the mouth and tongue
  • Prophylaxis/Treatment
  • Nystatin
  • Clotrimazole
  • BID for 3 months

65
Other Infections
  • BK Virus
  • Definition Polyomavirus causing a latent kidney
    infection that reactivates when patient is
    immunosuppressed
  • Usually occurs 6 months posttransplant
  • Symptoms increased creatinine
  • Diagnosis biopsy
  • Treatment decrease immunosuppression,
    Leflunomide and cidofovir

66
Post-transplant Lymphoproliferative Disorder
(PTLD)
  • Definition Malignancy after transplant possibly
    related to EBV infection
  • Symptoms fever, malaise, leukopenia, adenopathy,
    sore throat, graft dysfunction
  • Diagnosis Biopsy
  • Treatment Decrease immunosuppression, Chemo

67
Retransplantation
  • Failure
  • Immediate Post-Op Complication
  • Rejection
  • Recurrent Disease
  • Primary Non-function
  • Immunologic Factors
  • Increased PRA / Highly Sensitized
  • Exhausted possible living donor options

68

69
References
  • Annual Data Report. Retrieved March 5, 2012, from
    http//usrds.org
  • Clinical Practice Guidelines and Clinical
    Practice Recommendations 2006 Updates
    Hemodialysis, Peritoneal Dialysis, Vascular
    Access. Retrieved March 5, 2012, from
    www.kidney.org
  • Clinical presentation, evaluation, and diagnosis
    of acute kidney injury (acute renal failure) in
    children. Retrieved March 5, 2012, from
    http//www.Uptodate.com
  • Chronic Kidney Disease. Retrieved March 5, 2012,
    from http//www. kidney.org
  • Daugirdas, Blake, Todd. (2007). Handbook of
    Dialysis. Philidelphia Lippincottt WIlliams
    Wilkins.
  • KDOQI Clinical Practice Guidelines for Chronic
    Kidney Disease Evaluation, Classification, and
    Stratification, Retrieved March 5, 2012, from
    www.kidney.org
  • Smeltzer and Bare. (2000) Medical-Surgical
    Nursing. Philidelphia Lippincottt WIlliams
    Wilkins.
About PowerShow.com