Get Homework/Assignment Done Homeworkping.com Homework Help https://www.homeworkping.com/ Research Paper help https://www.homeworkping.com/ Online Tutoring https://www.homeworkping.com/ click here for freelancing tutoring sites I. INTRODUCTION Chronic or irreversible, renal failure is a progressive reduction of functioning renal tissue such that the remaining kidney mass can no longer maintain the body’s internal environment. CRF can develop insidiously over many years, or it may result from an episode of a cure renal failure from which the client has not recovered. Chronic renal failure affects many body systems. It can also lead to many complications. This is the goal of health 1
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I. INTRODUCTION
Chronic or irreversible, renal failure is a progressive reduction of
functioning renal tissue such that the remaining kidney mass can no longer
maintain the body’s internal environment. CRF can develop insidiously over
many years, or it may result from an episode of a cure renal failure from which
the client has not recovered.
Chronic renal failure affects many body systems. It can also lead to many
complications. This is the goal of health care providers, to prevent any
occurrence of complications. One of the complications of CRF is
hyperparathyroidism; this is due to the compensatory mechanism of the
parathyroid hormone once it detects any alteration in the calcium level of the
body.
It is important for clinicians to recognize the problem of
hyperparathyroidism early in the course of chronic kidney disease so that growth
of the parathyroid glands can be prevented or halted, and excessive secretion of
Renal Blood flow and Glomerular FiltrationThe kidney receive 20% to 25% of the cardiac output under resting
conditions, averaging more than 1 L of arterial blood per minute. The renal
arteries branch from the abdominal aorta at the level of he second lumbar
vertebra, enter the kidney, and progressively branch into lobar arteries. Blood
flows from the interlobular arteries through the afferent arteriole, the glomerular
capillaries, the efferent arteriole and the peritubular capillaries. Some of the
peritubular capillaries carry a small amount of blood to the renal medulla in the
vasa recta before entering the venous drainage. The blood leaves the kidney in
venous system closely corresponding to the arterial system: interlobular veins,
arcuate veins, interlobar veins, and the renal vein. The renal circulation then
empties into the inferior vena cava.
PhysiologyCharacteristics of Urine
Urine is a watery solution of nitrogenous waste an inorganic salts that are
removed from the plasma and eliminated by the kidneys. It is 5% water and 5%
dissolved solids and gases. The amount of these dissolved substances is
indicated by it specific gravity. The specific gravity of pure water, used as a
standard is 1.000. Because of the dissolved materials it contains, urine has a
specific gravity that normally varies from 1.010 to 1.040. When the kidneys are
diseased, they lose the ability to concentrate urine, and the specific gravity no
longer varies as it does when the kidneys function normally.
Urine formationThe chief function of the kidneys is to produce urine. Each part of the
nephrons performs a special function. There are three important processes by
which urine is formed. They are glomerular filtration, tubular reabsorption and
tubular secretion
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The path of the Formation of Urine
Electrolyte BalanceFluid and ElectrolyteS Balance are important constituents of body fluids.
These are compounds that separate into positively and negatively charged ions
and carry an electric current in solution. The main source of electrolytes is food.
A few of the most important ions are considered here.
1. Sodium- chiefly responsible for maintaining osmotic balance and body fluid
volume. It is the main positive in extracellular fluids. Sodium is required for
nerve impulse conduction and is important in maintaining acid-base balance.
2. Potassium- important in the transmission of nerve impulse; a major positive
ion in the intracellular fluids. It is involved in cellular enzyme activities and
helps regulate the chemical reactions by which carbohydrate is converted to
protein.
3. Calcium-required for bone formation, muscle contraction, nerve impulse
transmission, and blood clotting
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Blood enters the
Efferent
Now it becomes filtrate (blood minus RBC’s and plasma
protein
To Bowman’s capsule
Passes through the
Glomeruli
To the distal convulated
tubule
To the collecting tubule (at this about 99% of the filtrate
has been reabsorbed)
To the loop of HenleContinues through
the proximal convulated tubule
Approximately 1 ml of urine is formed per
minute
The 1 ml of urine goes to the renal
pelvis
To the ureterTo the bladder
To the urethra
To the urinary meatus
4. Phosphate- essential in the metabolism of carbohydrates, bone formation and
acid-base balance. They are found in the cell membrane and in the nucleic
acids.
5. Chloride- essential for formation of the hydrochloric acid of the gastric juice.
Electrolytes must be kept in the proper concentration in both intracellular and
extracellular fluids. Although some electrolytes are lost in the feces and through
the skin as sweat, the job of balancing electrolytes is left mainly to the
kidneys.There are several hormones that are involved in this process.
Aldosterone produced by the adrenal cortex promotes the reabsorption of sodium
and the elimination of potassium. Hormones from parathyroid and thyroid glands
regulate calcium and phosphate levels. Parathyroid hormones increases blood
calcium, levels by causing the bones to release calcium and by causing the
kidneys to reabsorb calcium. The thyroid hormone calcitonin lowers blood
calcium by causing calcium to be deposited in the bone .
Function of the Urinary SystemThe major functions of the urinary systems are performed by the kidneys and
the kidneys plays the following essentials roles in controlling the composition and
volume of body fluids:
1. Excretion. The kidneys are the major excretory organs of the body. They
remove waste products, many of which are toxic, from the blood. Most waste
products are metabolic by- products of cells and substances absorbed from
the intestine. The skin, liver, lungs, and intestines eliminate some of these
waste products, but they cannot compensate if the kidneys fail to function.
2. Blood volume control. The kidneys play an essential role in controlling
blood volume by regulating the volume of water removed from the blood to
produce urine.
3. Ion concentration regulation. The kidneys help regulate the concentration
of the major ions in the body fluids.
9
4. pH regulation. The kidneys help regulate the pH of the body fluids. Buffers in
the blood and the respiratory system also play important roles in the
regulation of pH
5. Red blood cell concentration. The kidneys participate in the regulation of
red blood cell production and therefore, in controlling the concentration of red
blood cells in the blood.
6. Vitamin D synthesis. The kidneys. Along with the skin and the liver,
participate in the synthesis of vitamin D.
Chronic Renal FailureChronic or irreversible, renal failure is a progressive reduction of
functioning renal tissue such that the remaining kidney mass can no longer
maintain the body’s internal environment. Chronic Renal failure can develop
insidiously over many years, or it may result from an episode of acute renal
failure from which the client has not recovered.
Precipitating Factors Chronic glomerular disease such as glomerunephritis
Chronic infections such as chronic pyelonephritis or tuberculosis
Congenital anomalities such as polycystic
Vascular diseases, such as renal nephrosclerosis or hypertension Obstructive processes such as calculi
Collagen diseases such as systemic lupus erythematosus
nephrotoxic agents such as long-term aminoglycoside
endocrine diseases such as diabetic neuropathy
Such conditions gradually destroy the nephrons and eventually cause
irreversible renal failure. Similarly, acute renal failure that fails to respond to
treatment becomes chronic renal failure.
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Predisposing Factors Sex- both sexes are affected by chronic renal failure. But in 1998, based on
United States Renal Data System, a higher total number of males with ESRD
was found
Age- CRF can be found in people of any age, from infants to the very old.
The elderly population also is the most rapidly growing ESRD population in
the United States. Note that age 30 years progressive physiological
glomerulosclerosis. Aging also results in concomitant progressive
physiological decrease in muscle mass such that daily urinary creatinine
excretion also decreases.
Clinical ManifestationsThe clinical manifestations of CRF are present throughout the body. No
organ system is spared.
Electrolyte imbalances
Electrolyte balance may be upset by impaired excretion and
utilization in the kidney. Although many clients maintain normal serum
sodium level, the salt-wasting properties of some failing kidneys, in
addition to vomiting and diarrhea, may cause hyponatremia. Because the
kidneys are efficient at excreting potassium, potassium levels usually
remain within normal limits until late in the disease.
Several mechanisms contriburte to hypocalcemia. Conversion of
25-hydroxycholecalciferol to 1,25-dihyroxycholecalciferol (necessary to
absorb calcium) is decreased, which results in reduced intestinal
absorption of calcium. At the same time, phosphate is not excreted, which
causes hyperphosphatemia. Because calcium and phosphate are
inversely related, a high phosphate level results in a reduced calcium
level.
Metabolic changes
In advancing renal failure, BUN and serum creatinine rise as waste
products of protein metabolism accumulate in the blood. The serum
creatinine level is the most accurate measure of renal function. The
11
proteinuria accompanying renal disease and sometimes inadequate
dietary intake of proteins cause hypoproteinuria, which lowers the
intravascular oncotic pressure. Metabolic acidosis occurs because of the
kidney’s inability to excrete hydrogen ions. Decrease reabsorption of
sodium bicarbonate and decreased formation of dihydrogen phosphate
and ammonia contribute to this problem. Acidosis accentuates
hyperkalemia and the reabsorption of calcium from the bones.
Hematologic changes
The primary hematologic effect of renal failure is anemia, usually
normochromic and normocytic. It occurs because the kidneys are unable to
produce erythropoietin, a hormone necessary for red blood cell production.
Frequently, the fatigue, weakness, and cold intolerance accompanying the
anemia lead to a diagnosis of renal failure.
Gastrointestinal changes
The entire gastrointestinal system is affected. Transient anorexia,
nausea, vomiting are almost universal. Clients often experience a constant
bitter , metallic, or salty taste, and their breath commonly smells fetid, fishy or
ammonia-like. Stomatitis, parotitis and gingivitis are common problems
because of poor oral hygiene and the formation of ammonia from salivary
urea. Accumulations of gastro may be a major cause of ulcer disease.
Esophagitis, gastritis, colitis, gastrointestinal bleeding, and diarrhea may be
present. Serum amylase level may be increased, although they do not
necessarily indicate pancreatitis.
Immunologic changes
Impairment of the immune system makes the client more susceptible
to infection. Several factors are involved, including depression of humoral
antibody formation, suppression of delayed hypersensitivity and decreased
chemotactic function of leukocytes. Immunosuppression is an important part
of the medical management of renal diseaes such as glomerulonephritis.
Cardiovascular changes
The most common clinical manifestation is hypertension, produced
through:
12
mechanism of volume overload, stimulation of the renin-angiotensin system,
sympatheically mediated vasoconstriction, absence of prostaglandins.
Respiratory changes
Some of the respiratory effects such as pulmonary edema can be
attributed to fluid overload. Metabolic acidosis causes a compensatory
increase in respiratory rate as the lungs try to eliminate excess hydrogen
ions.
Musculoskeletal changes
The etiologic mechanism involves the kidney-bone-parathyroid and
calcium-phosphate-vitamin D connections. As the GRF decreases, the
phosphate excretion decreases and calcium elimination increases. Abnormal
levels of calcium and phosphate stimulate the release of parathyroid hormone
that mobilizes calcium from the bones and facilitates phosphate excretion.
Integumentary changes
The skin is also often very dry because of atrophy of the sweat glands.
Severe and intractable pruritus may result from secondary
hyperparathyroidism and calcium deposits in the skin. The pallor of anemia is
evident.
NURSING ASSESSMENT
A. Personal Data and History (Demographic Data)
Mr. Ibrahim Daud is a 61-year-old male, married living in Kampung Pokok
Sena Pokok Sena Alor Setar Kedah. He was born on 7 April 1939.He is married
for 30 years now and has 9 children. He is a smooker. And according to him,
smoking helps him to be relaxed. He consumed 8 sticks/day. He worked as a taxi
driver for more than 20 years.
13
Mr. Ibrahim was admitted in Hospital Sultanah Bahiyah Alor Setar On Mac
10 2010. He was admitted due to body weakness and severe anemia. He was
discharged on .17 Mac 2010.
General Health History History of Past Illness
Mr.Ibrahim was known hypertension for being for 7 years. Mr. Ibrahim
consistently having his blood chemistry and creatinine check-up every month in
Klinik Kesihatan Pokok Sena.
History of Present IllnessFour days prior to admission, Mr.Ibrahim experienced easy fatigability. No
other accompanying signs and symptoms. His condition was persisted until one
day prior to admission, he already experiencing body weakness, body malaise,
pallor and fatigability . He was advised to have laboratory examination (Hgb and
Hct), which revealed anemia and he was advised to be admitted. His initial vital
signs were as follows: T-36.7, RR- 24, PR- 72, BP- 180/100.
Physical Examination Upon Admission:10/3/2010 Vital Sign:
T - 36.7
RR - 24
PR - 72
BP - 180/100
14
Integumentary
A. Skin- pallor, brown in complexion, with good skin turgor
B. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
Head-no mass palpated
A. Scalp- hair evenly distributed without any presence of lice and lesions
B. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
C. Ears- symmetrical with cerumen, no discharges noted
D. Nose- without flaring of nostrils, no discharges noted
E. Mouth- with dry and pale lips
F. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
G. Chest and Lungs- with bibasal rales
Abdomen- soft, flat, tender
GIT: loss of appetite
Renal and Urologic changes: fatigability, oliguria
Cardiovascular changes: hypertension
Hematopoietic changes: anemia
Skeletal changes: hypocalcemia and hyperphosphatemia
11/3/2010 Vital Signs:
T - 36.8
RR - 22
PR - 80
BP - 170/100
Integumentary
A. Skin- pallor, brown in complexion, with good skin turgor
15
B. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
Head-no mass palpated
A. Scalp- hair evenly distributed without any presence of lice and lesions
B. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
C. Ears- symmetrical with cerumen, no discharges noted
D. Nose- without flaring of nostrils, no discharges noted
E. Mouth- with dry and pale lips
F. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
G. Chest and Lungs- with bibasal rales
Abdomen- soft, flat, tender
Cardiovascular changes: hypertension
Renal and urologic changes: oliguria
Hematopoietic changes: anemia
12/3/2010 Vital Signs:
T - 36.9
RR - 18
PR - 78
BP - 170/100
Integumentary
A. Skin- pallor, brown in complexion, with good skin turgor
16
B. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
Head-no mass palpated
A. Scalp- hair evenly distributed without any presence of lice and lesions
B. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
C. Ears- symmetrical with cerumen, no discharges noted
D. Nose- without flaring of nostrils, no discharges noted
E. Mouth- (-) pallor, dry lips
F. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
G. Chest and Lungs- with bibasal rales
Abdomen- soft, flat, tender
Renal and Urologic changes: oliguria
Cardiovascular changes: hypertension
13/3/2010 Vital Signs:
T - 37
RR - 20
PR - 74
BP - 150/100
Integumentary
A. Skin- pallor, brown in complexion, with good skin turgor
17
B. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
Head-no mass palpated
A. Scalp- hair evenly distributed without any presence of lice and lesions
B. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
C. Ears- symmetrical with cerumen, no discharges noted
D. Nose- without flaring of nostrils, no discharges noted
E. Mouth- with (-) pallor, dry lips
F. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
G. Chest and Lungs- with bibasal rales
Abdomen- soft, flat, tender
Renal and Urologic changes: oliguria
Cardiovascular changes: hypertension
Hematopoietic changes: anemia
14/3/2010 Vital Signs:
T - 37
RR - 18
PR - 82
BP - 170/90
Integumentary
C. Skin- pallor, brown in complexion, with good skin turgor
D. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
18
Head-no mass palpated
H. Scalp- hair evenly distributed without any presence of lice and lesions
I. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
J. Ears- symmetrical with cerumen, no discharges noted
K. Nose- without flaring of nostrils, no discharges noted
L. Mouth- (-) pallor
M. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
N. Chest and Lungs- with bibasal rales
Abdomen- soft, flat, tender
Renal and Urologic changes: oliguria
Cardiovascular changes: hypertension
Hematopoietic changes: anemia
15/3/2010 Vital Signs:
T - 37
RR - 18
PR - 84
BP - 160/90
Integumentary
E. Skin- pallor, brown in complexion, with good skin turgor
19
F. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
Head-no mass palpated
O. Scalp- hair evenly distributed without any presence of lice and lesions
P. Eyes- no pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
Q. Ears- symmetrical with cerumen, no discharges noted
R. Nose- without flaring of nostrils, no discharges noted
S. Mouth- (-) pallor
T. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
U. Chest and Lungs- with bibasal rales
Abdomen- soft, flat, tender
Renal and Urologic changes: oliguria
Cardiovascular changes: hypertension
Hematopoietic changes: anemia
Diagnostic and Laboratory Procedures
Diagnostic/ Laboratory Procedure
Indication (s)Purpose (s) Result Normal
ValuesAnalysis and Interpretation
1.FBC
Hgb
Usually done to a pt. with renal disease to determine if the kidney’s ability to release erythorpoietin factor is already affected
7.17.58.88.99.09.510.1
13.0-17.0gm%
Results were all below the normal level, thus indicating renal malfunction and thereby causing anemia
20
Hct Used to measure RBC number and volume. It is an integral part of the evaluation of anemic patients
.23
.31
.33
.36
.32
.34
.37
40-.50 %
Result were all below the normal range thus, showing anemia and renal disease
WBCLeukocytes
Determines any inflammation and infection
11.769.018.408.588.58.08.2
5-10x109/L
Results were all above normal level. This shows presence of inflammation and infection
Neutrophils Determines any acute bacterial infection
81.75.71.72.74.72.79
50-.70 Results were all above normal level. This shows presence of bacterial infection
Lymphocytes Determines any chronic bacterial infection or viral infection
.17
.13
.20
.15
.13
.15
.14
.10-.40 Results were all within normal level. Showing absence of chronic infection
Monocytes Determines any acute bacterial infection
.05
.08
.04
.09
.07
.05
.08
.00-.07 Some of the results were all above normalLevel indicating presence of bacteria.
21
Eosinophils To determine any allergic reaction of the body
.04
.04
.04
.05
.04
.06
.06
.00-.07 Results were all within the normal level. This shows no allergic reactions.
Nursing Responsibilities:
1. Explain the procedure to the patient
2. Tell the patient that no fasting is required
3. Apply pressure or a pressure dressing to the venipuncture site
4. Assess the venipuncture site for bleeding
Diagnostic/ Laboratory Procedure
Indication (s)Purpose (s) Result Analysis and
Interpretation
2.Hepatitis Profile This is usually
done before proceeding in hemodialysis. This is to determine if the patient was expose to the virus of if there is presence of hepatitis virusIn the blood of the patient.
Result revealed that the patient has no hepatitis virus and was not exposed to any of it.
Nursing Responsibilities:
22
1. Explain the procedure to the patient
2. Tell the patient that no fasting is required
3. Apply pressure or a pressure dressing to the venipuncture site
4. Handle the specimen as if it were capable of transmitting hepatitis
5. Immediately discard the needle in the appropriate receptacle
6. Send the specimen to the laboratory promptly
Diagnostic/ Laboratory Procedure
Indication (s)
Purpose (s)Result
Normal Values used by
the hospital
Analysis and Interpretation
3.Urinalysis To diagnose and monitor renal or urinary tract disease
Color: straw, light yellow, light yellow
Appearance: slightly turbid
pH: 5
Specific Gravity:1.020, 1.025, 1.020
Albumin:3+
Sugar: negative
Pus Cells: 1-2/HPF, 0-2/HPF, 2-5 /HPF
Red cells: 1-3/HPF, 1-3/HPF,4-6/HPF
Epithelial Cells:Rare
Mucus thread:Rare, (-), (-)
Laboratory results revealed that there is presence of albumin in the blood; this indicates that the glomerular cannot filter large molecules such as that of albumin. It also revealed that there is bacterial infection as evidenced by presence of bacteria, pus cells and red cells in the urine.
23
Bacteria: (-), few, (-)
Amorphous urates:Moderate, moderate, few
Nursing Responsibilities:
1. Explain the procedure to the patient
2. Tell the patient that no fasting is required
3. Instruct the patient to catch the midstream urine for better result
4. Send the specimen to the laboratory promptly
Diagnostic/ Laboratory Procedure
Indication (s)Purpose (s) Result
Normal Values
used by the hospital
Analysis and Interpretation
4. Creatinine
5. Na+
This test was ordered in order to evaluate renal function.
To evaluate fluid and electrolyte imbalance and identify renal dysfunction
149914301649731730725500
137
62-106 umol/L
135-150 mmol/L
Results were all above the normal level indicating renal malfunction. The kidney cannot excrete nitrogenous waste product of protein leading to its accumulation in the blood
Normal result which means there is still fluid and electrolyte balance
Normal result which means there is still fluid and electrolyte balance
24
6. K+
7. Calcium
8. Phosphate
To evaluate fluid and electrolyte imbalance and identify renal dysfunction
To evaluate muscle contraction, nerve impulse transmission, and blood clotting
To evaluate the metabolism of carbohydrates, bone formation and acid-base balance.
4.78
6.4
186
3.5-5.5 mmol/L
8.5-10.5 mg/dl
30-150 u/L
Results were all above the normal level indicating renal malfunction.
Results were all above the normal level indicating renal malfunction.
Nursing Responsibilities:
1. Explain the procedure to the patient
2.Tell the patient that no fasting is required
3. Apply pressure or a pressure dressing to the venipuncture site
4. Assess the venipuncture site for bleeding
The Patient and his Care
Medical Management
Medical Management
General Description
Indication (s)Purpose (s)
Client’s initial reaction to
the treatment
Client’s response to the treatment
1. N/S A crystallized solution that is available in a variety of concentrated water and
To maintain fluid balance of the patient.
Patient felt discomfort Patient experienced bleeding and felt discomfort
Patient fluid status was maintained
25
2.. Subclavian catheterization
3.Blood Transfusion
4.Hemodialysis
calories are provided. It is hypertonic solution containing equal amounts of Na and Cl
A catheter tube is inserted into vein in either your neck, chest, leg or near the groin. It has two chambers to allow two-way flow of blood
It is intravenous replacement of loss or destroyed blood compatible citrated human blood it is also the introduction of whole blood or blood Component
Medical treatment used to promote excretion of wastes materials from the blood of patient.
Temporary access for hemodialysis
To immediately restore blood volume to treat severe anemia, to be able to maintain oxygen transport to the different parts of the body.
I
t is indicated for the patient because the kidneys cannot function very well to excrete the
on incision site
Patient was slightly nervous about the procuder..
During the blood transfusion, patient was chilling for a short period of time. There was no further adverse reaction noted upon the transfusion
Patient was slightly nervous about the treatment.
Patient did not show any further bleeding
Patient did manifest some reaction such as chilling but there was not further reaction after the treatment
There was no adverse reaction noted during and after the procedure
26
nitrogenous waste products, thus leading to its accumulation in the blood.
Hemodialysis
Hemodialysis schematic
Main articles: Hemodialysis and Home hemodialysis
In hemodialysis, the patient's blood is pumped through the blood compartment of
a dialyzer, exposing it to a partially permeable membrane. The dialyzer is
composed of thousands of tiny synthetic hollow fibers. The fiber wall acts as the
semipermeable membrane. Blood flows through the fibers, dialysis solution flows
around the outside the fibers, and water and wastes move between these two
solutions. [5] The cleansed blood is then returned via the circuit back to the body.
Ultrafiltration occurs by increasing the hydrostatic pressure across the dialyzer
membrane. This usually is done by applying a negative pressure to the dialysate
compartment of the dialyzer. This pressure gradient causes water and dissolved