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Chronic Renal Failure: A Crucial Topic 1

- http://www.healthline.com/blogs/health_observances/uploaded_images/kidney 713543.jpg
Chronic Renal Failure: A Crucial Topic 2

Chronic Renal Failure: A Crucial Topic

Remington N. Thomas II

HNFS 251-C71

Sharon Souter, RN, MSN, PhD, CNE

November 24, 2008


Chronic Renal Failure: A Crucial Topic 3

Abstract

Chronic renal failure or (chronic renal disease - CRD) is the slow deterioration of the

kidneys. The kidneys are the center of a complex blood filtration system. They remove waste

materials such as toxins and excess fluids from the blood stream.

The blood is provided to the kidneys through the renal arteries which branch off the main

artery which is known as the abdominal aorta. This artery is carrying oxygenated blood away

from the heart which enters the kidneys and then distributed through all the smaller and smaller

vessels and on to the capillaries that are arranged in tufts.

This is when blood filtration is done. Wastes are separated from the substances that the

body needs such as vitamins, minerals, etc…The substances that can be of use are reabsorbed

into the blood stream and the waste is excreted in the urine.

If the excretion of urine is obstructed, or if the components of the kidneys become

diseased or damaged, problems are likely to occur. This will interrupt the removal of wastes

from the blood stream by the kidneys and the body can react in a number of negative ways.
Chronic Renal Failure: A Crucial Topic 4

Kidney Structure and Function:

The kidneys are the main organs of excretion in the body, removing wastes and excess

water from the blood that would otherwise harm the body. The wastes and excess water removed

are excreted as urine. Two healthy kidneys excrete between 1.5 and 2.5 L of urine daily.

-http://lifeblood.anaemiaworld.com/en/chronic-kidney-disease/anatomy-of-the-kidneys.html
Chronic Renal Failure: A Crucial Topic 5

The kidneys, each about the size of a fist, are located near the center of the back, just

below the rib cage. Each kidney is surrounded by a membrane known as the renal capsule. The

kidney is bean-shaped, with 2 main regions: the

renal cortex (outer section) and the renal medulla (inner section).

Blood enters the kidney through the renal artery and exits through the renal vein. Urine

is carried away from each kidney by a ureter, which leads to the urinary bladder. The filtering of

the blood takes. The filtering of blood by the kidneys takes place in tiny functional units called

nephrons. There are approximately 1 million nephrons in each kidney. In addition to filtration,

nephrons perform the functions of reabsorption and secretion.

In the nephron, capillaries (tiny blood vessels) are intertwined with tubules (urine-

carrying tubes) that carry away wastes and water. Blood enters the nephron through the

glomerulus, a tuft of capillaries where filtration occurs. During filtration, blood fluid is forced

from capillaries into the tubules. As the fluid passes through the tubules, substances needed by

the body, including water, sodium, phosphorus, potassium, and glucose, are selectively

reabsorbed into the blood by the intertwined capillaries. In this way, the kidneys regulate the

level of these vital substances in the blood.

In addition to removing wastes, the kidney releases 3 important substances into body’s

blood the circulation:

• Erythropoietin, which stimulates the development of red blood cells

• Renin, an enzyme that is important in blood pressure regulation

• Calcitriol, an active form of vitamin D, which helps maintain calcium balance


Chronic Renal Failure: A Crucial Topic 6

I am writing this in order for it to serve as an educational tool. I will explain what kidney

disease is, its implications and I will provide a dietary plan which I believe will be practical and

very useful for the individual with chronic renal failure.

There is a high prevalence of chronic kidney disease in the United States, which has risen

over the past decade, according to a study led by researchers at the Johns Hopkins Bloomberg

School of Public Health. The study found that the overall prevalence of chronic kidney disease

increased from 10 percent of the population during a period from 1988-1994 to 13 percent from

1999-2004. The researchers conclude that the increase in chronic kidney disease is partly due to

the rise in number of Americans with diabetes and hypertension and the aging of the population

(ScienceDaily Nov. 9, 2007).

Chronic kidney failure (CRD) is the progressive loss of the kidneys' filtering ability. The

kidneys attempt to compensate for renal damage by hyper filtration (excessive straining of the

blood). This accelerated filtration with the remaining filtering units over time causes further loss

of kidney function.

Chronic loss of function causes generalized wasting (shrinking in size) and progressive

scarring within all parts of the kidneys. In time, overall scarring obscures the site of the initial

damage. Yet, it is not until over 70% of the normal combined function of both kidneys is lost that

most patients begin to experience symptoms of kidney failure. (Stanley J. Swierzewski III, S.J.,

M.D. 2001)

Chronic kidney disease (CKD) may result from any cause of renal dysfunction of

sufficient magnitude. The most common cause in the United States is diabetic nephropathy (an

abnormal state of the kidney), followed by hypertensive nephroangiosclerosis (sclerosis of the

renal arterioles reduces blood flow) and various primary and secondary glomerulopathies.
Chronic Renal Failure: A Crucial Topic 7

Metabolic syndrome in association with obesity, in which hypertension and type 2 diabetes are

present, is a large and growing cause of renal damage.

When kidney function is seriously impaired, dangerous levels of fluid and waste can

quickly accumulate in the body.

In the early stages of chronic kidney failure, there may have few signs or symptoms.

Many people with chronic kidney failure don't realize they have a problem until their kidney

function has decreased quite a significant amount from normal

The main goal of treatment of chronic kidney failure is to halt or delay progression of the

disease, usually by controlling the underlying cause. Chronic kidney failure can progress to end-

stage kidney disease, which is fatal without artificial filtering (dialysis) or a kidney transplant.

Progressive kidney damage most often results from a chronic illness over a period of years.

Loss of kidney tissue in chronic renal failure

http://www.cyclingnews.com/photos/2002/features/PRCA/anemia_kidneys_high.gif
Chronic Renal Failure: A Crucial Topic 8

Common causes include:

• Diabetes: Diabetes is a leading cause of chronic kidney failure in the United States.

Chronic kidney failure is related to both type 1 and type 2 diabetes.

• High blood pressure (hypertension): Elevated blood pressure can damage the

glomeruli and ultimately cause the nephrons containing damaged glomeruli to lose their

ability to filter waste from the blood.

• Obstruction of urine flow: An enlarged prostate, kidney stones or tumors, or

vesicoureteral reflux — a condition that results when urine backs up into the kidneys

from the bladder — can block urine flow, increasing pressure in the kidneys and reducing

their function.

• Kidney diseases: These include clusters of cysts in the kidneys, kidney infection and

inflammation of the tufts of capillaries that do most of the blood filtering, a condition that

causes the kidneys to leak protein into the urine and damages nephrons.

• Kidney artery constriction: This is a narrowing or blockage of the kidney (renal) artery

before it enters the kidney, which impairs blood flow and leads to kidney damage.

• Toxins: Ongoing exposure to fuels and solvents, such as lead, soldering materials,

jewelry and even alcohol distilled in old car radiators (moonshine) can lead to chronic

kidney failure.

Others include:

• Sickle cell disease

• Kidney disease present at birth (congenital) – polycystic kidney disease


Chronic Renal Failure: A Crucial Topic 9

A healthy kidney (left) eliminates waste from the blood and maintains the body's normal chemical balance. Fluid-

filled sacs (right), called cysts, characterize autosomal dominant polycystic kidney disease.

© 1998-2008 Mayo Foundation for Medical Education and Research (MFMER)

• Overexposure to some medications

• Family history of kidney disease

• Lupus erythematosus

• Age 60 or older

Symptoms:

Signs and symptoms may include some or many of the following:

• High blood pressure

• Decreased urine output or no urine output

• Darkly colored urine

• Anemia

• Nausea or vomiting
Chronic Renal Failure: A Crucial Topic 10

• Loss of appetite

• Sudden weight change

• A general sense of discomfort and unease (malaise)

• Fatigue and weakness

• Headaches that seem unrelated to any other cause

• Sleep problems

• Decreased mental sharpness

• Pain along apersons side or mid to lower back

• Muscle twitches and cramps

• Swelling of the feet and ankles

• Bloody or tarry stools, which could indicate bleeding in ther intestinal tract

• Yellowish-brown cast to the skin

• Persistent itching

Chronic kidney failure can be difficult to detect initially. Signs and symptoms are often

nonspecific, meaning they can also be attributed to other illnesses. In addition, because the

kidneys are highly adaptable and able to compensate for lost function, signs and symptoms of

chronic kidney failure may not appear until irreversible damage has occurred.

When to seek medical advice:

If a chronic medical condition exists that increases risk of chronic kidney failure, a doctor

is likely to monitor blood pressure and kidney function with urine and blood tests during

regularly scheduled office visits. Call a doctor if any of the signs and symptoms of chronic

kidney failure are experienced between visits.

Tests and diagnosis:


Chronic Renal Failure: A Crucial Topic 11

If the patient has diabetes,a doctor will likely schedule an annual test to measure small

amounts of protein in the urine (microalbuminuria). This test can screen for early kidney damage

related to diabetes (diabetic nephropathy).

If a doctor suspects chronic kidney failure, he or she is likely to order urine and blood

tests to check for increased levels of waste products, such as urea and creatinine. Also, have a

chest X-ray to check for fluid retained in the lungs (pulmonary edema) as well as tests to rule out

other possible causes for the signs and symptoms.

To help confirm a diagnosis of kidney failure, have the following tests:

• Ultrasound imaging: This test uses high-frequency sound waves and computer

technology to generate images of the kidneys. Ultrasound images can indicate the shape

and structure of the kidneys and reveal obstructions contributing to the problem.

• Computerized tomography (CT) scan: This test uses computers to create more detailed

images of your internal organs — including your kidneys — than conventional X-rays

do.

• Magnetic resonance imaging (MRI): Instead of X-rays, this test uses a magnetic field

and radio waves to generate cross-sectional pictures of your body.

• Kidney biopsy: Sometimes a doctor may remove a small sample of kidney tissue to be

examined microscopically. Kidney tissue analysis permits a more specific diagnosis of

the kidney disease.

A doctor confirms a diagnosis of end-stage kidney disease when blood tests consistently

show very high levels of urea and creatinine — a sign that kidney function has been severely and

permanently damaged.

Complications:
Chronic Renal Failure: A Crucial Topic 12

Chronic kidney failure can affect almost every part of the body. Potential complications

may include:

• Fluid retention, which could lead to swollen tissues, congestive heart failure or fluid in

the lungs (pulmonary edema)

• A sudden rise in potassium levels in the blood (hyperkalemia), which could impair the

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

• Cardiovascular disease

• Weak bones that fracture easily

• Anemia

• Stomach ulcers

• Dry skin, changes in skin color

• Insomnia

• Decreased sex drive or impotence

• Damage to the central nervous system

• Decreased immune response, which increases vulnerability to infection

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

(pericardium)

• Irreversible damage to the kidneys (end-stage kidney disease), requiring either dialysis or

a kidney transplant for survival

Complications in children:

Chronic kidney failure can cause children to stop growing normally. This complication

occurs partly because failing kidneys have reduced production of a hormone that helps generate

red blood cells and metabolize growth hormones. The kidneys also regulate the interactions of
Chronic Renal Failure: A Crucial Topic 13

calcium and vitamin D, both of which are essential for bone growth. In chronic kidney failure,

these interactions can become imbalanced, stunting the childs growth.

Complications during pregnancy:

If a pregnant woman is suffering from chronic kidney failure, she will face a number of

potential complications. While pregnant, the amount of fluid in the body increases greatly, so the

kidneys must work especially hard. This may lead to worsening high blood pressure and an

increase in the waste products circulating in the blood.

These changes affect both the woman and the baby. Chronic high blood pressure means

the baby receives less blood through the placenta, which can seriously affect growth. Waste

products in the bloodstream may have an adverse effect on the baby as well.

In addition, pregnant women with chronic kidney failure are at high risk of a serious

condition of late pregnancy which causes a dangerous rise in blood pressure. If not treated, it can

lead to hemorrhages in the brain, liver or kidneys, and ultimately may be fatal for both her and

her baby.

Treatments and drugs:

Chronic kidney failure has no cure, but treatment can help control signs and symptoms,

reduce complications, and slow the progress of the disease. If chronic kidney failure is occurring,

a doctor will likely refer the woman to a kidney specialist (nephrologist) if she isn’t seeing one

already.

Treating the underlying condition:

The first priority is controlling the condition responsible for the kidney failure and its

complications. If a person has diabetes or high blood pressure (hypertension), for instance, that

means carefully following a doctor's recommendations for diet and exercise and taking any
Chronic Renal Failure: A Crucial Topic 14

medications as directed. Most people with chronic kidney failure are treated with medications to

lower their blood pressure.

In addition, following a proper diet is extremely important in treating kidney failure

itself. Restricting the amount of protein consumed may help slow the progress of the disease. It

can also help ease such symptoms as nausea, vomiting and lack of appetite. It is also likely to

limit the amount of salt in ther diet to help control high blood pressure. Over time, restrictions

may also need to be placed on the amount of potassium and phosphorus consumed.

Nutrient Guidelines For Every Patient with Chronic Renal Failure:

• Calories: For an adequate intake of energy with CRF calories from a variety of

carbohydrate sources is need at 16 calories pound of body weight. The recommendation

drops to 13 calories per pound of body weight for individuals over the age of 60 due to a

more sedentary lifestyle.

• Sodium: For those with failing kidneys, sodium excretion eventually falls. Sodium

restrictions are mandatory to prevent things such as high blood pressure and heart failure.

It is literally impossible to take in NO sodium, because that's an element found in so

many foods, but it is possible to limit the amount in a diet. Thus, high sodium foods must

be eliminated.

• Fluids: Fluid intake must be monitored and carefully controlled. Some cases require

that it must be restricted. Your physician will set a limit for you, somewhere between four

and eight cups maximum per day. Fluid is defined as anything that melts at room

temperature, so in addition to water and juices, you must count ice cream, gelatin

desserts, sherbet, and watermelon.


Chronic Renal Failure: A Crucial Topic 15

• Potassium: Potassium counts, too, and it's harder to control for several reasons. You

can't taste it, like you can salt, it's not a required item to be listed in the nutritional

contents of packaged food, and it's in many foods. The highest potassium amounts are

found in nuts, avocados, potatoes, winter squash including pumpkin, oranges, kiwi,

peaches, apricots, and anything dried -- fruits, beans and lentils. Low potassium foods,

safest to include frequently in a renal patient's diet, include applesauce, black berries,

grapes, tangerines, canned pears and plums; asparagus, green or waxed beans, corn,

cauliflower, cucumbers, water chestnuts, and summer squash. Juices such as apple,

cranberry, lemonade, grape, and fruit-flavored drinks are okay; just remember to count

them in your fluid total for the day.

• Protein: In CRF the excretion of wastes declines so it is mandatory to control the level

of protein intake. It plays an important role in the diet of any kidney patient. The amount

must be limited to conserve kidney strength.

• Phosphorous: Begins to be a consideration once dialysis begins, also. Foods to avoid

based upon phosphorous content are dairy products, whole grains, bran and barley, nuts,

coconut, figs and dates, raisins, salmon, sardines, oysters, and organ meats. Cola drinks

are also high in phosphorous, but soft drinks that are light colored (7-Up and Sprite, club

soda) are fine. Meat, poultry, fish and eggs are high in phosphorous, but are still an

important part of the dialysis patient's diet because of the protein content; they should not

be limited. Yet, due to the importance of limiting the amount of phosphorous in the blood

stream, physicians will usually prescribe a "phosphate binder," (such as Tums) to be

taken in prescribed doses with each meal.


Chronic Renal Failure: A Crucial Topic 16

While it seems like an inordinate amount of food has been eliminated from a wise menu plan

for persons with renal failure, it is possible to have a healthy and delicious variety of food every

day. A daily plan based on the amount of protein recommended for the individual patient,

complemented by fresh, low-potassium fruits and vegetables and supplemented by low salty

snacks, not only tastes wonderful, but is worth the effort in the life-saving health benefits

achieved.

End-stage kidney disease:

By the time end-stage kidney disease develops, the kidneys are functioning at less than

10 percent to 15 percent of capacity. At this point, conservative measures used to treat chronic

kidney failure — diet, medications and controlling the underlying cause and complications —

are no longer enough. The kidneys aren't able to keep up with waste and fluid clearance on their

own, and dialysis or a kidney transplant becomes the only option to support life.

Exactly when it becomes necessary to start dialysis varies from person to person. In most

cases, doctors try to manage chronic kidney failure as long as possible because both dialysis and

transplantation may have potentially life-threatening complications.


Chronic Renal Failure: A Crucial Topic 17

Here is a case of chronic renal failure, hemodialysis and leg ischemia:

Leg ischemia is the condition when the leg does not receive the necessary amount of

oxygen (via the blood circulation) that is required for the activity underway.

His past medical history was noted:

• Hypertension - high blood pressure

• History of renal stones - a hard mineral and crystalline material formed within the kidney or

urinary tract contains calcium in combination with either oxalate or phosphate

• End-stage renal disease and dialysis for 3 years

• Nonischemic cardiomyopathy - a disease of the heart muscle. The heart loses its ability to pump

blood and, in some instances, heart rhythm is disturbed, leading to irregular heartbeats, or

arrhythmias

• Crohn's disease post colonic resection - surgical procedure to remove a part or the entire colon

(large intestine)

• Post cholecystectomy - surgical excision of the gallbladder

• Hypothyroidism - deficient activity of the thyroid gland; a resultant bodily condition

characterized by lowered metabolic rate and general loss of vigor

• Monoclonal protein - An antibody found in unusually large amounts in the blood or urine of

people with types of plasma cell tumors

• Thrombocytopenia - persistent decrease in the number of platelets in the blood that is often

associated with hemorrhagic conditions

• Vitamin B12 deficiency - a blood problem that occurs when there is not enough of this vitamin

in the body which can cause anemia.


Chronic Renal Failure: A Crucial Topic 18

• Peripheral vascular disease - a diseases of blood vessels outside the heart and brain, often

narrowing the vessels that carry blood to the legs, arms, stomach or kidneys. There are two types

of these circulation disorders: functional and organic.

• Former cigarette smoker


Chronic Renal Failure: A Crucial Topic 19

1996-2006 Circulator Boot Corporation in Association with Prime Healthcare Solutions


Chronic Renal Failure: A Crucial Topic 20

Kidney dialysis:

Dialysis is an artificial means of removing waste products and extra fluid from the blood.

The blood is pumped out of the body, cleaned by a machine and then pumped back into the body

when the kidneys are no longer able to perform these functions. It's not a miracle treatment, and

it presents significant risks, including infection. Yet, it can help prolong life for people with end-

stage kidney disease.

There are two main types of kidney dialysis, each with subtypes involving slightly different

techniques. They include:

Hemodialysis:

Hemodialysis removes extra fluids, chemicals and wastes from the bloodstream by

filtering the blood through an artificial kidney (dialyzer). Blood is pumped out of your body to

the artificial kidney through one of two routes; a catheter placed surgically in one of the main

blood veins, or a surgically created junction between a vein and artery in the arm. Inside the
Chronic Renal Failure: A Crucial Topic 21

artificial kidney, your blood moves across membranes that filter out waste before being returned.

- Adapted from National Institute of Diabetes and Digestive and Kidney Diseases.

-http://www.venofer.com/VenoferHCP/Venofer_kidneyFunction.html

Less than 1 cup (237 milliliters) of blood is outside the body in the dialyzer and tubing at any

one time. Hemodialysis is usually performed three times a week for three or more hours.

However, it's now recognized that more frequent dialysis — up to six times a week either

during the day or at night while the patient is sleeping — results in significantly better quality of

life, better control of complications and a reduction in risk of death. Newer, easy-to-use home

dialysis machines are making this option more feasible for many.
Chronic Renal Failure: A Crucial Topic 22

Peritoneal dialysis uses the peritoneal membrane, the lining of the abdomen, to remove

excess water, wastes, and chemicals from the body.10 A dialysate passes through the abdomen

via a surgically placed catheter. Fluid, wastes, and chemicals pass from capillaries in the

peritoneal membrane into the dialysate. After several hours, the waste-carrying dialysate is

drained from the abdomen.

There are 3 types of peritoneal dialysis:

• Continuous ambulatory peritoneal dialysis (CAPD)

• Continuous cyclic peritoneal dialysis (CCPD)

• Intermittent peritoneal dialysis (IPD)

Continuous ambulatory peritoneal dialysis is the most common type. The dialysate passes

from a plastic bag through a catheter and into the abdomen. No machine is necessary. After 4 to 6

hours, the solution is drained back into the bag and replaced with fresh solution. The solution is

usually changed 4 times a day.


Chronic Renal Failure: A Crucial Topic 23

- Adapted from National Institute of Diabetes and Digestive and Kidney Diseases.

-http://www.venofer.com/VenoferHCP/Venofer_kidneyFunction.html

Continuous cyclic peritoneal dialysis is like CAPD, except that a machine is used to fill and

drain the dialysate through the catheter.10 This procedure is performed nightly, for 10 to 12

hours, during sleep. Continuous cyclic peritoneal dialysis requires the help of a partner.

Intermittent peritoneal dialysis uses a machine, much like CCPD, to add and drain the

dialysate.10 Each session may last up to 24 hours. Intermittent peritoneal dialysis treatments are

usually performed in a hospital for a total of 36 to 42 hours weekly.

Hemodialysis and peritoneal dialysis are treatments that take over the function of the failed

kidneys but do not cure ESRD.10 Problems frequently associated with long-term dialysis include

bone disease, high blood pressure, nerve damage, and anemia.

Kidney transplant:

If no life-threatening medical conditions exist other than kidney failure, a kidney

transplant is usually a better option than dialysis, although the patient may need to undergo

dialysis temporarily until a suitable donor kidney becomes available.

A successful kidney transplant depends on finding the best immunologic match possible.

Ideally, the patient and the kidney's donor will have the same blood type, cell-surface proteins

and antibodies. The more closely these features are matched, the lower the risk that the body will

reject the new kidney. A sibling is likely to be the best donor. If that's not possible, another blood

relative, such as a parent, aunt, uncle or cousin, or even a non-blood-related adult may be

considered. When a living donor isn't available, tissue-typing centers throughout the country may
Chronic Renal Failure: A Crucial Topic 24

search for a cadaver kidney from an accident victim or other person who has offered to donate

organs after his or her death.

24 Hour Dietary Plan for Someone Suffering From Chronic Renal Failure:

• Breakfast:

- Coffee 8 oz. (240ml)

- Whole Milk, 2 Tbsp.

• Lunch:

- Hamburger & Bun, 4 oz. (113 g)

- French Fries, Large

- Iced Tea, 16 oz. (480 ml)

• Dinner:

- 2 Slices of Chicken Breast, 6 oz.

- Baked Potato, 1 medium


Chronic Renal Failure: A Crucial Topic 25

- Butter, 2 tsp.

- Broccoli & Spinach, ½ cup each

- Chocolate Cake, 1 slice

- Cola/Soda, 16 oz. (480 ml)

• Snack:

- Salted Nuts, small bag

- Cola/Soda, 16 oz. (480 ml)

Total Calories: 2493 kcal

Protein: 110 g (18 % of calories)

Fat: 98 g (35 % of calories)

Carbohydrate: 303 g (48 % of calories

Potassium: 3487 mg

Sodium: 1648 mg

References

Hark L, & Morrison G. (2003). Medical Nutrition & Disease: A case Based Approach (3rd.

ed). Malden, MA: Blackwell Science.

Shils M., & Olson J., & Shike M., (1994). Modern Nutrition and Health and Disease (8th. Ed)

Malvern, PA: Lea & Febiger.

National Kidney Foundation. (2008)., Nutrition and Chronic Kidney Disease. Retrieved Nov. 1,

2008 from http://www.kidney.org/atoz/atozitem.cfm?id=95

Silberberg C., Chronic Renal Failure., New York Medical College, Division of Nephrology,

Valhalla, NY. Review provided by VeriMed Healthcare Network. Retrieved Nov. 4, 2008

from http://www.nlm.nih.gov/medlineplus/ency/article/000471.htm
Chronic Renal Failure: A Crucial Topic 26

Merck Online Medical Library (2008)., Chronic Kidney Disease (Chronic Renal Failure).

Retrieved Nov. 6, 2008 from http://www.merck.com/mmpe/sec17/ch233/ch233c.html

Dr. Wadhwa., Chronic Renal Failure. Retrieved from Stony Brook University Hospital,

Department of Medicine, Division of Nephrology and Hypertension Web site:

http://www.uhmc.sunysb.edu/internalmed/nephro/webpages/Part_G.htm

Arora, P., (2008, September). Chronic Renal Failure. Retrieved Nov. 5, 2008 from

http://www.emedicine.com/med/topic374.htm

Mayo Clinic Staff, (May 13, 2008 ) Kidney failure, Chronic. Retrieved November 7, 2008 from

http://www.mayoclinic.com/health/kidney-failure/DS00682

Curtis, B., Brendan, J. & Levin, A (2001, December). Identifying and Slowing Progressive

Chronic Renal Failure. Canadian Family Physician, Vol. 47