Farmakoterapi Gagal

Ginjal

Dr. Diana Laila Ramatillah, M. Farm, Apt

PhD Clinical Pharmacy
Dr. Aprilita Rina Yanti Eff., M.Biomed., Apt.
Gagal Ginjal

• Acute Kidney Disease (Gagal Ginjal Akut)

• Chronic Kidney Disease (Gagal Ginjal Kronik)
Gagal ginjal akut
Gagal ginjal akut didefinisikan oleh Kidney Disease: Improving Global
Outcomes (KDIGO) sebagai penyakit yang memenuhi setidaknya satu
dari hal-hal ini:
•Peningkatan kreatinin serum ≥ 0.3 mg/dL dalam kurun waktu 48 jam,
atau
•Peningkatan kreatinin serum ≥ 1.5 kali dari nilai dasar yang
diperkirakan terjadi dalam kurun waktu 7 hari, atau
•Keluaran urin kurang dari 0.5 mL/kgBB/jam dalam kurun waktu 6 jam

3
patofisiologi dari gagal ginjal akut
• Prerenal, akibat hipoperfusi ke ginjal yang menyebabkan penurunan
LFG (laju filtrasi glomerulus), seperti pada hipovolemia, gangguan
fungsi jantung, vasodilatasi sistemik dan peningkatan resistensi
vaskular
• Renal, akibat gangguan yang terjadi dalam ginjal seperti tubulus,
glomerulus, interstisial dan pembuluh darah intrarenal
• Pasca renal, akibat dari adanya obstruksi pada traktus urinarius
dimulai dari tubulus ginjal hingga uretra dimana terjadi peningkatan
tekanan intratubular
Manajemen GGA :
• Preventif menghindari obat nephrotoxic atau menjaga
keadaan euvolemia & tekanan perfusi ginjal
• Menghilangkan penyebab/komplikasi
• supportive care
• terapi obat:
• menjaga keseimbangan cairan elektrolit & asam-basa
• mendapatkan nutrisi optimal

7
 DIURETIK

• Meningkatkan output urine

• Meningkatkan RBF dgn efek vasodilator

8
Diuretik
Terapi lii pertama:
• Loop diuretik: dosis awal 40-80 mg iv
• mannitol scr parenteral 12,5-25 g dlm 20% lrt infus iv
selama 3-5 menit monitor : output urine, elektrolit
serum & osmolalitas

9
Dopamin
• penggunaan pd GGA masih kontroversial
• dosis rendah (0,5-2 μg/kg/menit)
• dilatasi vaskuler renal
• meningkatkan RBF & GFR
• dosis tinggi : mengikat reseptor β & alfa adrenergik 
vasokonstriksi ginjal & penurunan GFR

10
 Obat Vasoactive
• Infus dobutamin (175 μg/min) memperbaiki Ccr tanpa
meningkatkan output urine (pasien dgn Ccr 70-80 ml/min)
• mekanisme : peningkatan output jantung & RBF
• Fenoldopam : agonis selektif reseptor dopamin-1 
vasodilatasi arteriola ginjal & natriuresis

11
 Gagal Ginjal kronis

 sindroma klinis akibat penurunan fungsi ginjal yg

menahun, progresif dan menetap
 GGT (end stage) = tingkat Gagal ginjal tahap akhir
yg dapat menyebabkan kematian kecuali
dilakukan terapi pengganti
12
Klasifikasi CKD
1. Dari Nilai GFR
Stage Description GFR (ml/min/1,73 Related Terms
m2)
1 Kidney Damage with normal or ≥ 90 Albuminuria, Proteinuria,
increasing of GFR Hematuria
2 Kidney damage with mild reducing of 60-89 Albuminuria, Proteinuria,
GFR Hematuria
3A Midly to moderately decrease 40-59 Chronic Renal Insufficiency,
3B Moderately to severely decreased 30-44 Early Renal Insufficiency
4 Severe reducing of GFR 15-29 Chronic Renal Insufficiency,
Late Renal Insufficiency, Pre-
ESRD
5 Kidney Failure < 15 (or dialysis) Renal failure, Uremia, End-
Stage Renal Disease
2. Dari Nilai Albumin

Stage Description Albumin

A1 Normal to mildly increased < 30 mg/g
< 3 mg/mmol
A2 Moderately increased 30-300 mg/g
3- 30 mg/mmol
A3 Severely increased > 300 mg/g
> 30 mg/mmol
Tanda-Tanda CKD
No Component Causal

1 Symptoms and Signs of Early Stages of CKD  Weakness

2 Symptoms and Signs of Late (Uremic)
Stages of CKD
 Decreased appetite
 Nausea
 Changes in urination (polyuria, frequency)
 Blood in urine or dark-colored urine
 Foamy or bubbly urine
 Loin pain
 Edema
 Elevated blood pressure
 Pale skin
 General (lassitude , fatigue , elevated blood pressure , signs of volume overload ,
decreased mental acuity , intractable hiccups , uremic fetor )
 Pulmonary (dyspnea , pleural effusion , pulmonary edema , uremic lung )
 Cardiovascular (periCardial friction rub ,congestive heart failure )
 Gastrointestinal ( anorexia , nausea , vomiting, weight loss , stomatitis , unpleasant taste in
the mouth )
 Neuromuscular ( muscular twitches , peripheral sensory and motor neuropathies, muscle
cramps , restless legs ,sleep disorders , hyperrefl exia , seizures , encephalopathy , coma )
 Endocrine-metabolic ( decreased libido , amenorrhea , impotence )
 Hematologic ( anemia , bleeding diathesis )
Perhitungan ClCr
1. MDRD (Modification of Diet in Renal
Disease) equation

• GFR in mL/min per 1.73 m2 = 186.3x(serum creatinine)

−1.154 x(age)-0.203x (1.210 if black)x(0.742 if female)
2. Cockcroft−Gault equation
• Creatinine clearance in mL/min = {[(140 −age) x
weight in kg] / (72x serum creatinine in mg/dL)}x(0.85
if female).
Adoted from Google Image and
Also Comparing with Kidney
Disease Guideline
The Process of The CKD (Chronic Kidney
Disease)

Adopted from Kidney Disease

Guideline
The Process of The CKD (Chronic Kidney
Disease)

Adopted from Kidney Disease

Guideline
Komplikasi Penyakit Ginjal
 Penatalaksanaan konservatif
1. Memperlambat progresifitas:
a. pengendalian tek.darah
b. diet rendah protein, rendah fosfat
c. mengendalikan proteinuria & hiperlipidemi
d. obati ISK dg.antibiotik non-nefrotoksik
e. Obati asidosis metabolik dg NaHCO3 tab/I.v.
f. Obati hiperurisemi/kelainan sendi dg.diet
&obat

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 Penatalaksanaan konservatif
2. Mencegah kerusakan lebih lanjut:
a. hindari nefrotoksik:OAINS, aminoglikosid, kombinasi
sefalosporin dg. Furosemid.
b. hindari gangguan elektrolit.
c. Hindari dehidrasi, hipovol., antihipertensi yg terlalu
kuat,diuretik berlebihan.
d. Hindari kateterisasi urine yg tidak perlu.
e. Obati decomp.cordis agar CO membaik.

24
 Penatalaksanaan konservatif
3. Mengurangi gejala uremia:
a. diet rendah protein(GFR 5-10% 40-50g/h; GFR 4-5% protein
20-30 g/h; kalori harus> 2500 kal/hari
b. Gatal(pruritus): Diet TKRP, radiasi UV, difenhidramin
paratiroidektomi, transplantasi ginjal
c. memperbaiki asidosis dengan NaHCO3
d. neuromusk: vit.B1, B6, B12 dosis tinggi, diazepam
e. Anemia: preparat Fe., asam folat, nandrolon dekanoat,
hormon anabolik untuk menstimulasi eritropoetin
f. osteodistrofi renal: koreksi asidosis, obat pengikat fosfat,
suplementasi kalsium, vitamin D3.
4. Bila terapi konservatif gagal : dialisis / transplantasi. 25
Definition HD (Hemodialysis)
Hemodialysis is a process or one of the treatments in replacing renal
function to excrete metabolism residual (Kidney Disease Guideline)
Process of Hemodialysis

Fig 1. Description of Hemodialysis

(www.wikipedia.org)
 
Hemodialysis
• End-stage renal disease can be treated by renal replacement therapies, such as Hemodialysis
(HD), Transplantation, and Peritoneal Dialysis (PD) (Indian Society of Nephrology, 2014).
• HD increases expected lifetime of the patients minimizing the effects of neurological
complications (Denhaerynck, 2007; Goksan, Kaarali-Savrun, Ertan, & Saurun, 2004) and
improves serum creatinine, albumin and prealbumin, normalises the protein catabolic rate
(nPCR) as well as increases the dietary intake of patients (N. B. M. Yusop, Mun, Shariff, & Huat,
2013).
• Despite its advantages, HD is highly associated with malnutrition and lower quality of life (QOL)
(T. Chang, Nam, Shin, & Kang, 2015). Severe malnutrition among HD patients in Malaysia was
reported to be approximately 4.6% - 19%, while 72% - 90.9% are mildly malnourished (N. B. M.
Yusop et al., 2013).
• Hemodialysis dose given is generally 2 times a week with each hemodialysis for 5 hours or as
many as three times a week with each hemodialysis for 4 hours (Goksan et al., 2004).
Laboratory Values of HD Patients
Baseline laboratory values (hemoglobin, serum creatinine, urea,
albumin, calcium, phosphate, and urea reduction ratio) were the mean
values of the first 3 months of dialysis measured during routine
monthly blood work and this must be recorded for all HD and PD
patients (Williams et al., 2011).
Continue,..
• Monitoring of pre-dialysis biochemical and hematological parameters
should be performed monthly for hemodialysed patients who
undergo hemodialysis in the hospital (Mactier et al., 2007).
Hemodialysed patients will experience rising PTH level due to
hypocalcemia and reduced the active form of vitamin D (International
Society of Nephrology, 2017). Hence, assessment of PTH level should
be conducted regularly (International Society of Nephrology, 2017).
Continue,..
• Attention must be given to the rise of PTH level to avoid complication
such as bone mineral disorder due to the lower of calcium level
(Tentori et al., 2015).
The Monitoring of HD Process
No Time Process
 Record weight of patient
1 Before Hemodialysis  Measure Blood Pressure in lying and standing position
 Assess patient for any new symptoms and examine patient
 Plan target Ultra Filtration (UF) and assess dry weight of patient
 
 
 The patient’s BP should be monitored and recorded as often as
2 During Hemodialysis necessary.
 In an unstable patient the BP should be checked every 15 minutes.
 In a stable patient BP is checked every 30 - 60 minutes.
 In diabetic patients attempts should be made to measure the
capillary blood glucose levels to detect any episode of hypoglycemia.
 
 Measure blood pressure
3 After Hemodialysis  Record the UF done
 Measure post dialysis weight
 
Clinical Practice Pattern of HD
• Usually, hemodialysis center in all of the hospitals will do the
treatment process appropriate with the guideline that they used. One
of the guidelines which was famous for hemodialysis ward is KDOQI
Clinical Practice Guideline Hemodialysis (National Kidney Foundation,
2015).
Continue,..
• According to the clinical practice guidelines, the frequency of hemodialysis is three times per week, the
duration should not be less than 4 hours for every session with careful consideration, meanwhile
hemodialysed patients who had frequency of hemodialysis two times in a week should get a higher sessional
dose of dialysis (Mactier, Nephrologist, Infirmary, & Glasgow, 2007).
• National Kidney Foundation guideline described the type of hemodialysis based on the frequency and
duration to be followed by physician or hemodialysed patients as shown in Table 1. Heart failure and fluid
overload are common and a major cause of morbidity and mortality in the dialysis population, hence, the
proper duration of dialysis should be considered (Arbor Research Collaborative, 2013).
Table 1
Proposed Name Time of Day Duration Frequency (sessions
(hours per Session) per week)
Conventional HD Day time 3–5 3
Frequent HD      
Short Day time <3 5–7
Standard Day time 3–5 5–7
Long Night time 5–7 5–7
Long HD      
Long Thrice Weekly Night time or >5 3
Daytime
Long every other night Night time >5 3.5
Long frequent Night time >5 5–7
Hepatitis Complication
• Hepatitis B or hepatitis C is one of the greater risk of seroconversion which is
common among hemodialysed patients (D. A. Goodkin et al., 2001).
• According to Ministry of Health India guideline, the hemodialysed patient is
particularly susceptible to several infections both bacterial occasioned by the
decreased immunity and blood borne viral infections. Bacterial infection is adding
a higher short term mortality and also rising the risk of long term cardiovascular
complications according to some studies (Ministry of Health & Family Welfare
Govt. of India, n.d.).
• The important infections that usually develop in hemodialysed patients include
viral infections such as hepatitis B and C, HIV and bacterial infections, especially
those involving vascular access.
 
Quality of Life Patients on HD
• One of the purpose for continues treatment or medication is to
increase quality of life of the hemodialysed patients. Hemodialysis is
one of the continuous treatment of renal failure. One of the
instruments to assess the quality of life patients is Kidney Disease
Quality of Life-24 (KDQoL-24).
• This instrument is valid and available in the RAND-health website. The
instrument has the English language version and some translated into
other language. If a translate version of the purposed country is not
available then instrument must be translated to into purpose country
language and pilot study is required to assess and reliability for that
country.
Continue,…
• In the KDQoL-24, there were 24 questions with 4 categories of
questions; health (11 questions), kidney disease (3 questions), effects
of kidney disease on daily life (8 questions) and satisfaction with care
(2 questions). The RAND website also provide the manual scoring
(manual standard) as a guideline to determine the value of the quality
of life based on KDQoL SF-36. Hence the manual standard can also be
used for KDQoL SF-24.
 Common risk factors
Kidney Failure
•Uremic toxins
Death
•Endocrine abnormalities; anemia and vitamin D and klotho
deficiency
•Sympathetic nervous system activation
•Chronic kidney disease mineral bone disorder; fractures, Dialysis-related factors
•Vascular access and infection
vascular calcification
•Accelerated aging •Blood loss and intravenous iron requirement
•Inflammation and oxidative stress •Rapid electrolyte and lipid volume changes
•Impaired antibacterial defences •Post-dialysis fatigue
•Electrolyte abnormalities •Immune system activation
•Volume overload •Bio incompatible peritoneal dialysis fluids
•Protein structure modification •Poorly understood consequences of calcium and alkali
•Altered lipid and lipoprotein profile and function balance
•Potential viral contamination
•Hemodialysis water impurities
Arteriosclerosis; arterial
Atherosclerosis
stiffness

Ischemia Diastolic dysfunction and left

ventricular hypertrophy Transplantation-related factors
•Major surgery (once)
Replacement of renal function? •Immunosuppress drugs
Increased infection
Increased malignancy
Adverse Cardiovascular risk
profile
No renal replacement Dialysis: insufficient Transplantation: •Chronic rejection: inflammation
therapy corrections of all partial or full
renal functions corrections of all
Death renal functions
Continue Factors of Death among HD
Patients
• it was explained that artherosclerosis, ischemia, diastolic dysfunction and left
ventricular hyperthropy are asscociated with death among hemodialysed
patients. Beside that, vascular access and infection, blood loss and intravenous
iron supplement, rapid electrolyte and lipid volume changes, post dialysis fatigue,
immune system activation, potential viral contamination and hemodialysis water
impurities are other factors associated with death during dialysis process.
 Factors to Reduce Risk of Death
Table 2.9 Factors that Reduce Risk of Death in Dialysis Patients*
• *Adopted from guideline (Ministry of Health & Family Welfare Govt. of India, n.d.)

No Component Process
1 Dialysis time Greater than four hours
 
2 Pre dialysis BUN Between 70 - 90 mg/dl with adequate
protein Catabolic rate (PCR)
 
3 Erythropoietin & antihypertensive drugs Requirement for the low dose
4 Plasma albumin Greater than 4 gms/dl
5 Plasma cholesterol Between 200 - 300 mg/dl
 
6 Pre dialysis creatinine Greater than 12.5 mg/dl
 
Hemodialysis in Indonesia
• Indonesia is one of the countries that have high prevalence of
hemodialysed patients (Prdjosudjadi, W., Suhardjono, 2009). Lack of
publication related to hemodialysis in Indonesia made Indonesian
Renal Registry (IRR) report one of the valid data available on issue
about hemodialysis, causes, prevalence and mortality incidence.
Distribution of Gender for Hemodialysed patients from 2007
to 2012 in Indonesia*

Year Male (N) Female (N)

2007 1113 772
2008 1157 779
2009 2864 1843
2010 3154 2030
2011 4180 2771
2012 5602 3559
Distribution of Age for Hemodialysed
patients in 2012 in Indonesia*

No Age (years New Patient Active Patient up Active Patient up to

old) to 30th June 31th Des

1 ≤ 14 0.41% 0.22% 0.19%

2 15-24 2.96% 2.11% 2.87%

3 25-34 7.73% 8.99% 8.70%

4 35-44 15.49% 17.46% 18.85%

5 45-54 27.82% 30.26% 29.21%

6 55-64 24.19% 25.92% 26.06%

7 >65 21.41% 15.03% 14.11%

The Percentage of AKI, ARF and ESRD
Patient in 2012 in Indonesia*

Disease Percentage Patient Number

AKI 5% 874

ARF 12% 1893

ESRD 83% 13213

The Etiology Related to Hemodialysed
Patients in 2012 in Indonesia*

Disease Percentage Patient Number

Hypertension 35% 5654

Nephropathy Diabetic 26% 4199
GNC (Glomerulopathic Primer) 12% 1966
PNG (Pyelonephritis Chronic) 7% 1083
Nephropathy Uric Acid 2% 224
Polytheistic Renal 1% 169
Others 6% 989
No Data 2% 359
The Causes of Mortality Among
Indonesian Patients on Hemodialysis in
2012*

Causes Percentage Number of

Patients
Cardiovascular 47% 1557
Cerebrovascular 12% 395
GI Bleeding 5% 157
Sepsis 13% 433
Others 8% 274
No Data 15% 516
Medication
• Prescribing medication should be based on the guideline and it should
cover all conditions in terms of the effects caused by end-stage renal
disease. Every patient has different condition due to severity of
disease and type of complication.
 No List of The Drugs
1 Supplement to prevent from loss of calcium

-IV alpha Calcitriol 1 mcg 3 times/week

-Rocaltriol 0.25 microgram 3 times/week
-IV Bonky 2 mcg 3x/week
-IV Bonky 3 mcg 3x/week
-Calcitriol 0.25 mcg 3x/week
-Rocaltriol 0.75 mcg 3x/week
-Calcitriol 0.75 mcg 3x/week
-Rocaltriol 0.5 mcg 3x/week
-Calcitriol 0.5 mcg 3x/week
-Calcitriol 0.25 mcg 2x/week
-IV Bonky 1 mcg 3x/week
-alpha Calcidol 4 mcg/ week
-alpha Calcidol 0.5 mcg 3 times/ week
-alpha Calcidol 2 mcg 3 times/ week
-IV Calsijex 4 mcg 3 times/week
-IV Calsijex 2 mcg 3 times/week + RoCaltriol 1,25 mcg OD
 No List of The Drugs
4 Antidiabetic drugs

-Insulin
-Gliquidone 30 mg BD
-Gliquidone 30 mg OD
-Gliquidone 15 mg OD
-Linagliptin 5 mg OD
-Novorapid insulin
-Gliclazide 80 mg OD
-S/C mixtard 10/10
-S/C mixtard 20/16
-Gliclazide 40 mg OD
-Actrapid 18ii TDS + Insulatard 26ii ON
-Actrapid 14ii TDS + Insulatard 16ii ON
-S/C mixtard 22/18
-Actrapid 20ii TDS + Insulatard 20ii ON
-S/C mixtard 18/16
-S/C mixtard 36/26
-SC Mixtard 14/4 BD
-SC Mixtard 12/1 BD
5 Cardiovascular drugs

-Nitrokaf 5 mg OD
-ISDN 5 mg OD
-Nitrokaf 5 mg OD + Miozidine 35 mg BD
-Nitrokaf 2.5 mg OD
-Adalat 10 mg OD
-Nitrokaf 5 mg BD
-ISDN 5 mg BD + Nitrokaf 2.5 mg OD
-Nitrokaf 2.5 mg BD
-Vasteral 20 mg tds + Digoxin 0,0625 mg
-Digoxin 0.0625 mg
-Isordil 10 mg TDS
-Adalat 10 mg TDS
-Adalat 20 mg TDS
-Vasteral 20 mg TDS
-Vasteral 20 mg BD + Trimetazidine 20 mg BD
-Vasteral 20 mg TDS + Isordil 10 mg TDS
6 Dyslipidemia drugs
 

-Simvastatin 20 mg ON
-Lipanthyl 300 mg OD
-Lovastatin 20 mg ON
-Simvastatin 40 mg ON
-Lovastatin 40 mg ON
-Simvastatin 40 mg ON + Gemfibrozil 300 mg BD
-Simvastatin 20 mg ON
-Gemfibrozil 300 mg OD + Simvastatin 20 mg ON
-Atorvastatin 40 mg ON
-Simvastatin 10 mg ON
-Atorvastatin 20 mg ON
-Gemfibrozil 300 mg BD
7 Antiplatelet

-Clopidogrel 75 mg OD
-Aspilet 80 mg OD + Clopidogrel 75 mg OD
-Aspirin 75 mg OD
-Aspirin 150 mg OD
-Cardiprin 100 mg OD
-Clopidogrel 75 mg OD
-Glyprin 1/1 OD
 Continue,..
• Using of supplement to prevent from loss of calcium (calcitriol/rocaltriol) will cover
the reduction of calcium level in the body (Galvao, Nagode, Schenck, & Chew,
2013; Quarles, Davida, Schwab, Bartholomay, & Lobaugh, 1988; Sauders, 2003).
• Some studies have shown small reductions in both systolic and diastolic pressures
from the use of supplement to prevent from loss of calcium (I. Reid et al., 2005; I.
Reid, Ames, & Mason, 2010; I. R. Reid, Bolland, Sambrook, & Grey, 2011).
• It can be caused by the effect of supplement to prevent from loss of calcium in
reduction of cardiovascular disease complication among hemodialysed patients (I.
R. Reid et al., 2011) and as mentioned in some studies and guidelines that
cardiovascular disease will increase probability of dying among those patients
(Culleton et al., 2007; K/DOQI Work Group, 2005).
Continue…
• Erythropoietin recombinant was given to hemodialysed patients who had anemia. The lower
hemoglobin level from the normal value is one of the anemia indicators. Hemoglobin level
prolonged the duration of hemodialysis among hemodialysed patients in a HD center Penang,
Malaysia. The lowering of hemoglobin level indicates the anemia in hemodialysed patients
(Berns, 2006; Marry Anne & Alledredge, 2013). Almost all those patients have a chance to get it
due to the reduction of erythropoietin in the (Marry Anne & Alledredge, 2013; Mcallister, Li, Liu,
& Simonsmeier, 2018). Erythropoietin is a hormone to help bone marrow to produce red blood
cells (Marry Anne & Alledredge, 2013; Mcallister et al., 2018; Price, 2008).
References
• (K/DOQI) Kidney Disease Outcomes Quality Initiative. (2004). K/DOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic
Kidney Disease. Am J Kidney Dis, 43(Supp 1), S1-290.
• Abboud, H., & Henrich, W. (2010). Clinical Practice Stage IV Chronic Kidney Disease. New England Journal of Medicine, 362, 56–65.
• Almeida, F. A. De, Ciambelli, G. S., Bertoco, A. L., Jurado, M. M., Siqueira, G. V., Bernardo, E. A., Gianini, R. J. (2015). Family Clustering of Secondary Chronic Kidney
Disease with Hypertension or Diabetes Mellitus. A Case-Control Study. Ciência & Saúde Coletiva, 20(2), 471–478. https://doi.org/10.1590/1413-
81232015202.03572014
• Annual Data Report Minnepolis. (2006). Renal Data System U.S.
• Arora, P. (2016). Medscape: chronic Kidney Disease Treatment & Management.
• Association, U. K. R., Mactier, R., Nephrologist, C., Infirmary, G. R., & Glasgow, N. H. S. G. (2007). Clinical Practice Guidelines Module 2 : Haemodialysis.
American Journal of Kidney Diseases.
• Barclay, L. (2013). CKD: KDIGO Guidelines Recommend Wider Use of Statins.
• Besarab, A., & W.Coyne, D. (2010). Iron Supplementation to Treat Anemia in Patients with Chronic Kidney Disease. Nature Reviews Nephrology, 6(12), 699–710.
• Biesenbach, G., & Pohanka, E. (2011). Antidiabetic Therapy in Type 2 Diabetic Patients on Hemodialysis. Special Problems in Hemodialysis Patients, 85–97.
• Bohlke, M., Nunes, D. L., Marini, S. S., Kitamura, C., Andrade, M., & Von-Gysel, M. P. O. (2008). Predictors of quality of life among patients on dialysis in
southern Brazil. São Paulo Medical Journal = Revista Paulista de Medicina, 126(5), 252–6.