Management of the Adult with Renal Failure

Management of the Adult with Renal Failure

Renal Failure The loss of kidney function
The types of renal failure include acute renal failure and chronic renal failure are caused by the retention of wastes, the retention of fluids and the inability of the kidneys to regulate electrolytes

Risks associated with renal disorders
Associated medical conditions Contact sports Family history of renal disease Frequent urinary tract infections High-sodium diets History of hypertension Medication use Trauma and injury

Terms Oliguria Anuria Arterial steal syndrome Azotemia
Urine output of less than 400ml a day Anuria Urine output less than 100ml per day Arterial steal syndrome Can develop following the insertion of an AV fistula when too much blood is diverted to the vein and arterial perfusion to the hand is compromised Azotemia The retention of nitrogenous waste products in the blood

Chronic Renal Failure (CRF)
The progressive loss and ongoing deterioration of kidney function that occurs slowly over a period of time. Irreversible Results in uremia or end-stage renal disease CRF requires dialysis or kidney transplant to maintain life

Acute Renal Failure The SUDDEN loss of kidney function
Caused by renal cell damage from ischemia or toxic substances Occurs abruptly Reversible Leads to hypoperfusion, cell death, and decomposition in renal function The prognosis is dependent on the cause and condition of the patient Near-normal or normal kidney function may resume gradually

Renal Failure Prerenal causes include Intrarenal causes
Intravascular volume depletion Decreased cardiac output Vascular failure secondary to vasodilation or obstruction Intrarenal causes Tubular necrosis Nephrotoxicity Alterations in renal blood flow Postrenal causes Instruction of urine flow between the kidney and urethral meatus and bladder neck obstruction

Acute Renal Failure Phases of ARF Oliguric Diuretic Recovery Causes
Infection Renal artery occlusion Obstruction Acute kidney disease Dehydration Diuretic therapy Ischemia from hypovolemia, heart failure, septic shock, or blood loss Toxic substances such as medications, particularly antibiotics

Acute Renal Failure Oliguric Phase Duration is 8 to 15 days
The longer the duration, the less chance of recovery Sudden drop in urine output less than 400mL/day Anorexia, nausea, vomiting Hypertension Decreased skin turgor Pruritus Tingling of the extremities Drowsiness progressing to disorientation to coma Edema Dysrhythmias Signs of CHF and pulmonary edema Signs of pericarditis Signs of acidosis

Acute Renal Failure Oliguric Phase
Glomerular Filtration Rate (GFR) decreases Hyperkalemia Sodium level normal or decreased Fluid overload Elevated BUN and Creatinine Urine SpGr of to 1.016

Acute Renal Failure Diuretic Phase
Urine output rises slowly and then diuresis occurs (4 to 5 L/day) Excessive urine output indicates recovery of damaged nephrons Hypotension Tachycardia Improvement in LOC

Acute Renal Failure Diuretic Phase
Glomerular Filtration Rate begins to increase Hypokalemia Hyponatremia Hypovolemia Gradual decline in BUN and Creatinine

Acute Renal Failure Recovery Phase A slow process
Complete recovery may take 1 to 2 years Urine volume is normal increase in strength Increase in LOC BUN is stable and normal Patient can develop CHRONIC RENAL FAILURE

Acute Renal Failure Recovery Phase (Convalescent)
BUN is stable and normal Complete recovery may take 1 to 2 years

The progressive loss and ongoing deterioration in kidney function that occurs slowly over a period of time It occurs in stages IRREVERSIBLE Results in uremia or end-stage renal disease Affects all major body systems Requires dialysis or kidney transplant to maintain life Hypervolemia can occur owing to the inability of the kidneys to excrete sodium and water, or hypovolemia can occur owing to the inability of the kidneys to conserve sodium and water

Causes May follow ARF Renal artery occlusion Chronic urinary obstruction Recurrent infections Hypertension Metabolic disorders Diabetes mellitus Autoimmune disorders

Assessment Anorexia and nausea Headache Weakness and fatigue Hypertension Confusion and lethargy, followed by convulsions and coma Kussmaul respirations Diarrhea or constipation Muscle twitching and numbness of the extremities

Assessment Decreased urine output Decreased urine SpGr Proteinuria Anemia Azotemia Fluid overload and signs of heart failure Uremic frost: a layer of urea crystals from evaporated perspiration that appears on the face, eyebrows, axilla, and groin in patients with advanced uremic syndrome

Nursing Implementation Monitor vital signs Monitor urine and I and O (hourly with ARF) Monitor weight, noting that an increase of 0.5 to 1 lb daily indicates fluid retention Monitor BUN, creatinine, and electrolyte values Monitor for acidosis and treat with sodium bicarboonate as prescribed Assess urinalysis for protein, hematuria, casts, and SpGr

Nursing Implementation Monitor LOC Assess for signs of infection, since the patient may not demonstrate a temperature or an increased WBC Assess for dysrhythmias, since potassium level above 6mEq/L will cause peaked T waves and a widened QRS complex

Nursing Implementation Monitor for fluid overload; assess lungs for rales and rhonchi Monitor for edema Administer prescribed diet; usually a moderate protein intake (to decrease the workload on the kidneys) and a high- carbohydrate, low-potassium, and low-phosphorus diet is prescribed

Nursing Implementation Restrict sodium intake as prescribed, based on the electrolyte level Daily fluid allowances may be 400mL to 1000mL plus measured urinary output

Nursing Implementation Administer sodium polystyrene sulfonate (Kayexalate) to lower the potassium level as prescribed Be alert to the mechanism for metabolism and excretion of all prescribed medications Be alert to nephrotoxic medications, such as antibiotics, which may be prescribed Prepare the patient for dialysis as prescribed

Special Problems in Renal Failure
Hypertension Failure of the kidneys to maintain homeostasis of the blood pressure Monitor vital signs Maintain fluid and sodium restrictions as prescribed Administer diuretics and Antihypertensives as prescribed Administer propranolol (Inderal), a beta-adrenergic antagonist, as prescribed, which decreases renin release (renin eventually causes vasoconstriction)

Hypervolemia Monitor vital signs Monitor I and O and weight Monitor for edema Monitor electrolytes Monitor for hypertension Monitor for CHF and pulmonary edema Enforce fluid restriction Avoid the administration of IV fluids Administer diuretics as prescribed

Hypervolemia (continued) Instruct the patient to avoid antacids or cold remedies containing sodium bicarbonate

Hypovolemia Monitor vital signs Monitor I and O and weight Monitor for edema Monitor electrolytes Monitor for hypotension Monitor for dehydration Provide replacement therapy based on the electrolyte results Provide sodium supplements as prescribed depending on the electrolyte value

Potassium Retention Monitor vital signs and apical rate Monitor potassium level Monitor for dysrhythmias (peaked T waves and widened QRS complex) indicating hyperkalemia Provide a low-potassium diet Administer medications as prescribed to lower the potassium level Prepare the patient for dialysis

Phosphorus retention Phosphorus rises and calcium drops, which leads to stimulation of parathyroid hormone, causing bone demineralization Treatment is aimed at lowering serum phosphorus levels Administer aluminum hydroxide preparations or other phosphate binders, as prescribed, that bind phosphorus in the intestine and allow the phosphorus to be eliminated

Phosphorus retention (continued) Administer aluminum hydroxide preparations at meals and not with other medications, because they bind medications in the intestinal tract Administer stool softeners and laxatives as prescribed to prevent constipation, because aluminum hydroxide preparations are constipating Enforce phosphorus restriction in the diet

Low calcium Occurs because of the high phosphorus level and because of the inability of the diseased kidney to activate vitamin D The absence of vitamin D causes a poor absorption of calcium from the intestinal tract Monitor calcium level Administer calcium supplements as prescribed Administer activated vitamin D as prescribed

Metabolic Acidosis The kidneys are unable to excrete hydrogen ions or manufacture bicarbonate, resulting in acidosis Administer alkalyzers such as sodium bicarbonate as prescribed Note that patients with CHF adjust to low bicarbonate levels and do not become acutely ill

Anemia a decreased rate of production of RBCs occurs as a result of the diseased kidney and the decreased secretion of erythropoetin Monitor hemoglobin and hematocrit Administer epoetin alfa (Epogen) as prescribed to stimulate the production of RBCs Administer folic acid (vitamin B9) as prescribed, instead of oral iron, because oral iron is not well absorbed by the GI tract in CRF and causes nausea and vomiting

Anemia Administer blood transfusions as prescribed, but blood transfusions are prescribed only when necessary because they decrease the stimulus to produce RBCs Monitor bleeding Instruct patient to use a soft toothbrush Administer stool softeners as prescribed Avoid the administration of acetylsalicylic acid (ASA) because the medication is excreted by the kidneys; and if administered, high toxic levels will occur and prolong bleeding time

GI Bleeding Urea is broken down to ammonia by the intestinal bacteria, and ammonia is a mucosal irritant that causes ulceration and bleeding Monitor hemoglobin and hematocrit levels Monitor stools for occult blood

Infection and Injury Infection and injury need to be monitored and avoided because tissue breakdown causes increased potassium levels Monitor for signs of infection Avoid urinary catheters and provide strict asepsis during insertion and catheter care Instruct patient to avoid fatigue, which decreases body resistance Instruct patient to avoid persons with infections Administer antibiotics as prescribed, monitoring for nephrotoxic effects

Pruitis Urate crystals are excreted through the skin to rid of excess wastes This deposit of crystals is called uremic frost, and it is seen in advanced stages of renal failure Monitor for skin breakdown, rash, and uremic frost Provide good skin care and oral hygiene Avoid the use of soaps Administer antipruritics as prescribed

Muscle Cramps Occur in the extremities and hands and can be due to electrolyte imbalances Monitor electrolytes Administer electrolyte replacements as prescribed Administer heat and massage as prescribed

Occular irritation Calcium deposits in the conjuctiva cause burning and watering of the eyes Administer medications to control the calcium and phosphorus levels as prescribed Administer lubricating eye drops

Insomnia and fatigue The diseased kidneys cause a buildup of wastes, causing fatigue in the patient Provide adequate rest periods Administer mild CNS depressants as prescribed

Neurological changes The buildup of active particles and fluids causes changes in the brain cells and leads to confusion and impairment in decision-making ability Monitor for confusion and monitor LOC Protect the patient from injury Provide a safe and hazard-free environment

Neurological changes (continued) Use side rails as needed Provide a calm and restful environment Provide comfort measures and backrubs Psychosocial problems: monitor patient for depression, anxiety, suicidal behavior, denial, dependence/independence conflict, and changes in body image

Hemodialysis The process of cleaning a patient’s blood
The diffusion of dissolved particles from one fluid compartment into another across a semi permeable membrane The patient’s blood flows through one fluid compartment, and the dialysate is in another fluid compartment

Hemodialysis Functions
Cleanses the blood of accumulated waste products Removes the by-products of protein metabolism, such as urea, creatinine, and uric acid Removes excessive fluids Maintains or restores the body’s buffer system Maintain or restores electrolyte levels

Hemodialysis Principles
The semi permeable membrane is made of a thin, porous cellophane The pore size of the membrane allows small particles to pass through, such as urea, creatinine, uric acid, and water molecules Proteins, bacteria, and blood cells are too large to pass through the membrane The patient’s blood flows into the dialyzer; the movement of substances occurs from the blood to the dialysate

Hemodialysis Diffusion Osmosis Ultrafiltration
The movement of particles from an area of greater concentration to one of lesser concentration Osmosis The movement of fluids across a semi permeable membrane from an area of lesser concentration of particles to an area of greater concentration of particles Ultrafiltration The movement of fluid across a semi permeable membrane as a result of an artifically created pressure gradient

Hemodialysis Dialysate Bath Composed of water and major electrolytes
Needs not to be sterile because bacteria are too large to pass through; however, the dialysate must meet specific standards, and water treatment systems are used to ensure a safe water supply

Hemodialysis Nursing Implementation Monitor vital signs
Monitor laboratory values before, during, and after dialysis Assess the patient for fluid overload prior to the procedure Assess patency of the blood access device Weigh the client before and after the procedure to determine fluid loss

Hemodialysis Nursing Implementation (continued)
Hold antihypertensives and other medications that can affect the BP prior to the procedure as prescribed Hold medications that could be dialyzed off, such as water-soluble vitamins and certain antibiotics Monitor for shock and hypovolemia during the procedure Provide adequate nutrition (client may eat prior to procedure

Complications of Hemodialysis
Disequilibrium Syndrome A rapid change in the composition of the extracellular fluid (ECF) occurs during hemodialysis Solutes are removed from the blood faster than from the Cerebrospinal fluid (CSF) and brain Fluid is pulled into the brain, causing cerebral edema

Disequilibrium Syndrome
Nursing Implementation Monitor for signs Notify physician Reduce environmental stimuli Prepare to dialyze patient for shorter period at reduced blood flow rates to prevent occurrence Assessment Nausea and vomiting Headache Hypertension Restlessness and agitation Confusion Seizures

Dialysis Encephalopathy
An aluminum toxicity that occurs as a result of aluminum in the water sources used in dialysate, and the ingestion of aluminum-containing antacids (phosphorous binders)

Assessment Progressive neurological impairment Mental cloudiness Speech disturbances Dementia Muscle incoordination Bone pain Seizures

Nursing Implementation Monitor for signs of dialysis encephalopathy Notify the physician if signs of dialysis encephalopathy occur Administer aluminum-chelating agents as prescribed so that the aluminum is freed up and dialyzed from the body

Access for Hemodialysis
Subclavian and femoral catheter May be inserted for short-term or temporary use in ARF May be used until a fistula or graft matures or develops, or when the client has fistula or graft access failure because of infection or clotting Assess insertion site for hematoma, bleeding, dislodging, and infection Do NOT use these catheters for any reason other than dialysis Maintain an occlusive dressing

Subclavian Vein Catheter
Is usually filled with heparin and capped to maintain patency between dialysis treatments The catheter should not be uncapped The catheter may be left in place for up to 6 weeks if complications do not occur

Femoral Vein Catheter The client should not sit up more than 45 degrees or lean forward, or the catheter may kink and occlude Assess extremity for circulation, temperature, and pulses Prevent pulling or disconnecting of the catheter when giving care Use an IV control pump with microdrip tubing if a heparin infusion is prescribed

External Arteriovenous shunt (AV Shunt)
Access is formed by the surgical insertion of 2 silastic cannulas into an artery and a vein in the forearm or leg, to form an external blood path The cannulas are connected to form a U shape; blood flows from the client’s artery through the shunt into the vein A tube leading to the membrane compartment of the dialyzer is connected to the arterial cannula

Blood fills the membrane compartment and flows back to the client by way of a tube connected to the venous cannula When dialysis is complete, the cannulas are clamped and reattached to form their U shape

Advantages Can be used immediately following creation No venipuncture is necessary for dialysis Disadvantage External danger of disconnecting or dislodging Risk of hemorrhage, infection, clotting Skin erosion around the catheter site can occur

Nursing Implementation Avoid wetting the shunt A dressing is completely wrapped around the shunt and kept dry and intact Cannula clamps need to be available at the bedside Do NOT take a blood pressure, draw blood, place an IV, or administer injections in the shunt extremity Monitor for hemorrhage, infection, clotting Monitor skin integrity around the insertion site Note that the shunt is patent if it is warm to touch Auscultate and palpate for a bruit, although a bruit may not be heard and is not always felt with the shunt Notify the MD immediately if signs of clotting, hemorrhage, or infection occur

Signs of clotting Fold back the dressing to expose the shunt tubing and assess for signs of clotting Fibrin-white flecks noted in the tubing The separation of serum and cells The absence of a previously heard bruit Coolness of the tubing or extremity Patient C/O of a tingling sensation

Internal Arteriovenous shunt (AV Fistula)
Access of choice for CRF – dialysis Created surgically by anastomosis of an artery in the arm to a vein; creating an opening or fistula between a large artery and a large vein The flow of arterial blood into the venous system causes the veins to become engorged (mature or developed) Maturity takes about 1 to 2 weeks and is required before the fistula can be used, so that the engorged vein can be punctured with a large-bore needle for the dialysis procedure Subclavian or femoral catheters, peritoneal dialysis, or an external AV shunt can be used for dialysis while the fistula is maturing or developing

Advantages Since the fistula is internal, there is less danger of clotting and bleeding The fistula can be used indefinitely Decreased incidence of infection No external dressing is required Allows freedom of movement

Disadvantages Cannot be used immediately after insertion Needle insertions are required for dialysis Infiltration of the needles during dialysis can occur and cause hematomas Arterial steal syndrome can develop (too much blood is diverted to the vein, and arterial perfusion to the hand is compromised) CHF can occur from the increased blood flow in the venous system

Internal Arteriovenous graft (AV Graft)
The internal graft is used primarily for chronic dialysis clients who do not have adequate blood vessels for the creation of a fistula An artificial graft made of Gore-Tex or bovine (cow) carotid artery is used to create an artificial vein for blood flow The procedure involves the anastomosis of the graft to the artery, a tunneling under the skin, and anastomosis to a vein The graft can be used 2 weeks after insertion Complications of the graft include clotting, aneurysms, and infection

Advantages Since the graft is internal, there is less danger of clotting and bleeding The graft can be used indefinitely Decreased incidence of infection No external dressing is required Allows freedom of movement

Disadvantages Cannot be used immediately after insertion Needle insertions are required for dialysis Infiltration of the needles during dialysis can occur and cause hematomas An aneurysm can form in the graft Arterial steal syndrome can develop CHF can occur with the AV graft also

Nursing Implementation of AV fistula and AV graft
Do NOT measure a BP, draw blood, place an IV, or administer injections in the fistula or graft extremity Monitor for clotting C/O tingling or discomfort in the extremity Inability to palpate a thrill or auscultate a bruit over the fistula or graft Monitor for arterial steal syndrome Palpate or auscultate for bruit or thrill over the fistula or graft Palpate pulses below the fistula or graft, and monitor for hand swelling as an indication of ischemia Note temperature and capillary refill of the extremity Monitor for infection Monitor lung and heart sounds for signs of CHF Notify the physician immediately of signs of clotting, infection, or arterial steal syndrome occur

Peritoneal Dialysis The peritoneum is the dialyzing membrane (semi permeable membrane) and substitutes for kidney function during kidney failure Works on the principles of diffusion and osmosis, and the dialysis occurs via the transfer of fluid and solute from the bloodstream through the peritoneum The peritoneal membrane is large and porous, allowing solutes and fluid to move via an osmotic gradient from an area of higher concentration in the body to an area of lower concentration in the dialyzing fluid The peritoneal cavity is rich in capillaries; therefore, it provides a ready access to blood supply

Peritoneal Dialysis Contraindications to peritoneal dialysis
Peritonitis Recent abdominal surgery Abdominal adhesions Impending renal transplant

Peritoneal Dialysis Dialysate Solution Solution is sterile
Contains electrolytes and minerals, a specific osmolality, a specific glucose concentration, and other medication additives as prescribed The higher the glucose concentration, the greater the amount of fluid removed during the exchange Increasing the glucose concentration increases the concentration of active particles that cause osmosis, and increases the rate of ultrafiltration and the amount of fluid removed Potassium: if hyperkalemia is not a problem, potassium may be added to each bag of solution Heparin: added to the dialysate solution to prevent clotting of the catheter Antibiotics: may be added to prevent peritonitis Insulin: may be added for clients with DM

Peritoneal Dialysis Access
a surgical insertion of a siliconized rubber catheter into the abdominal cavity is required to allow infusion of dialysis fluid The preferred insertion site is 3 to 5 cm below the umbilicus because this area is relatively avascular and has less fascial resistance The catheters are tunneled under the skin to stabilize the catheter and reduce the risk of infection

Peritoneal Dialysis Over a period of 1 to 2 weeks following insertion, there is an ingrowth of fibroblasts and blood vessels into the cuffs of the catheter, which fix the catheter in place and provide an extra barrier against dialysate leakage and bacterial invasion

Types of Peritoneal Dialysis
Continuous ambulatory peritoneal dialysis (CAPD) Closely resembles renal function because it is a continuous process Does not require a machine for the procedure Promotes client independence The client performs self-dialysis 24 hours a day, 7 days per week Usually for dialysis cycles are administered in 24 hours, including 8-hour dwell time overnight One and a half to two liters of dialysate is instilled into the abdomen four times daily and allowed to dwell as prescribed

Continuous ambulatory peritoneal dialysis (CAPD) The dialysis bag, attached to the catheter, is folded and carried in the client’s clothing until time for outflow. After dwell, the bag is placed lower than the insertion site so that fluid drains by gravity flow When full, the bag is changed, new dialysate is instilled into the abdomen, and the process continues

Automated Peritoneal Dialysis (APD) Similar to CAPD in that it is a continuous dialysis process Requires a peritoneal cycling machine Can be done as intermittent (IPD) Can be done as continuous cycling (CCPD) Or nightly (NPD)

Types of Automated Peritoneal Dialysis
CCPD Requires a peritoneal cycling machine 3 1 cycle w/8HR dwell in morning No exchanges during day Peritoneal cavity is opened only for the ON and OFF procedures, reducing risk of infection

Types of Automated Peritoneal Dialysis
IPD Requires a peritoneal cycling machine Not a continuous dialysis procedure Performed for 10 to 14 hours, 3 to 4 times a week NPD Performed 8 to 12 hours each night with no daytime exchanges or dwells

Peritoneal Dialysis Infusion
One infusion (inflow), dwell, and outflow is considered one exchange Uses an open system that presents a risk of infection Inflow: the infusion of 1 to 2 liters of dialysate as prescribed is infused by gravity into the peritoneal space, which usually takes about 10 minutes Dwell time: the amount of time the dialysate solution remains in the peritoneal cavity; prescribed by the physician Outflow: fluid drains out of body by gravity into the drainage bag

Nursing Implementation before treatment Monitor vital signs Obtain weight Have client void, if possible Assess electrolytes and glucose levels Nursing Implementation during treatment Monitor for signs of infection respiratory distress, pain, discomfort pulmonary edema Hypotension, hypertension Malaise, nausea, vomiting

Nursing Implementation during treatment (continued) Assess the catheter site dressing for wetness or bleeding Monitor dwell time as prescribed by physician and initiate outflow Do not allow dwell time to extend beyond the physician’s order – it increases the risk for hyperglycemia Turn the client side to side or have the client sit upright if the flow is slow to start Monitor outflow, which should be a continuous stream after the clamp is opened Monitor outflow for color and clarity Monitor I and O accurately If outflow is <inflow, the difference is equal to the amount absorbed or retained by the client during dialysis and should be counted as intake

Complications of Peritoneal Dialysis
Peritonitis Maintain meticulous sterile technique when hooking up or clamping off bags, and when caring for the catheter insertion site Follow institutional procedure for hooking up and clamping off bags, which may include scrubbing the connection sites with an antiseptic solution Monitor temperature closely Monitor for fever, cloudy outflow, and rebound tenderness If peritonitis is suspected, obtain a culture of the outflow to determine the infective organism Administer antibiotics as prescribed

Abdominal pain Pain during inflow is common during the first few exchanges, is caused by peritoneal irritation, and usually disappears after a week or two of dialysis treatments The cold temperature of the dialysate aggravates the discomfort, and the dialysate should be warmed before use, only with a special dialysate warmer pad Place a heating pad on the abdomen during the inflow to relieve discomfort

Insufficient outflow May be caused by catheter migration out of the peritoneal area; if this occurs, the catheter must be repositioned by the physician Insufficient outflow can also be caused by a full colon Maintain the drainage bag below the client’s abdomen

Insufficient outflow Change the client’s outflow position by turning or ambulating Check for kinks in the tubing Encourage a high-fiber diet Administer stool softeners as prescribed

Leakage around the catheter site Over a period of 1 to 2 weeks following insertion of the catheter, an ingrowth of fibroblasts and blood vessels into the cuffs of the catheter occurs, which fix the catheter in place and provide an extra barrier against dialysate leakage and bacterial invasion It may take up to 2 weeks for the client to tolerate a full 2-liter exchange without leaking around the catheter site

Characteristics of outflow During the first or initial exchanges, the outflow may be bloody; outflow should be clear and colorless thereafter Brown outflow indicates bowel perforation If the outflow is same color as urine, this indicates bladder perforation Cloudy outflow indicates peritonitis

Uremic Syndrome The accumulation of nitrogenous waste products in the blood because of the inability of the kidneys to filter out these waste products May occur as a result of Acute or Chronic Renal Failure

Uremic Syndrome Assessment Oliguria
Presence of protein, RBCs, casts in the urine SpGr of 1.010 Elevated levels of urea, uric acid, potassium and magnesium in urine Hypotension or hypertension Alterations of LOC Electrolyte imbalances Stomatitis Nausea and vomiting Diarrhea or constipation

Uremic Syndrome Nursing Implementation Monitor vital signs
Monitor electrolyte values Monitor I and O Provide a diet low in protein unless client is on PD Limit sodium, nitrogen, potassium, and phosphate intake as prescribed

Management of the Adult with Renal Failure

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