1. Hemodialysis in Children
Dr. Khalid Al-alsheikh MD
Director of Nephrology & Dialysis Center
Consultant Pediatric Nephrologist
Afhsr, Khamis Mushayt, ksa

2. Introduction
In children with chronic kidney disease as GFR declines to less 30ml/min/1.73 m2 ( Stage 4 CKD)
Preparation for renal replacement therapy are needed.
The child and his family should be provided with information related to preemptive kidney transplantation
Peritoneal dialysis
Hemodialysis
Renal replacement therapy is initiated in children with CKD stage 5 in some children with CKD stage 4
Hemodialysis in children progress over last 20 years
Morbidity of the session has decreased
Technological progress, the availability of ESA and GH enhanced dialysis dose and increase quality of life
Technically all children can underwent HD even infants

3. Indication of RRT Renal function, ?GFR Fluid status
Before uremic symptoms
Fluid status
Biochemical abnormalities
Acute renal failure
Oligoanuric
Resistant volume overload to medical treatment
Hyperkalamia resistant to medical treatment
Persistent metabolic acidosis resistant to medical treatment
Uremic encephalopathy
Uremic pericarditis
Inborn error of metabolism
Intoxication

4. Incidence of ESRD in Children
ESRD in children is uncommon
Incidence in USA 14.8 / Million
New Zealand 13.6 / million
Japan 4 / million
The choice of RRT children:
¼ underwent preemptive renal transplantation
½ started in peritoneal dialysis
¼ started in hemodialysis
Preemptive kidney transplantation which is performed prior to the need of dialysis.
Renal transplantation is associated with better quality of life (Growth and Development)

5. Pediatric Dialysis in Saudi Arabia
HD Patients above 75 years and below 15 years of age 2012
Below 15 years (1.8%)
(91.4%)
Above (6.8%)
PD patients adult and children 2012
Children 172/1327 = 13%
Adults 1155/1327 = 87%
SCOT Annual Report 2012

6. Epidemiology of chronic kidney disease in children
Pediatr Nephrol (2012) 27:363–373وJérôme Harambat & Karlijn J. van Stralen &Jon Jin Kim & E. Jane Tizard

7. Chronic Renal failure in children in Asir Region of Saudi Arabia
N. Alharbi Saudi Journal of Kidney Disease and Transplantation 1997 V8 Issue 3 pp

8. Chronic Renal failure in children in Western Area of Saudi Arabia
Jameela A. Kari Saudi Journal of Kidney Disease and Transplantation year 2006 V17 Issue I pp 19-24

10. Comparison of RRT Modalities in Children

11. Choices of Dialysis When preemptive transplantation is not an option
the choices between the two forms of dialysis is generally dictated by patients age, technical, social, compliance issues and family preference.

13. Principle of Vascular Access
Deliver adequate flow rate
Has long use life
Has low rate of complications
- Infection
- Stenosis
- Thrombosis
- Aneurysm
- Limb ischemia

14. The best is AVF
USA - CVC used most often more than AVF and graft
- CVC 89% For children<13 Years
64% YEARS
Review of 2006 annual reports (NAPRTCS) reveals that in a family of pediatric patients 78.9% receiving HD have CVC as primary access.
AVF 12.3%
AVG 8.5%

15. AV Fistula con’t. PREFERRED SITE FOR AVF IN CHILDREN Radiocephalic
Brachiocephalic
Brachiobasilic with or without transposition
Alternative:
Ulnar artery to basilic vein
Femoral artery to saphenous vein
Nondominant forearm

16. Definite guidelines regarding minimal vessel sites don’t exist
General consensus preferred of minimum 2.5 mm venous diameter
Doppler U/S scanning or venography can provide information regarding adequate:
A) vessel size
B) venous stenosis

17. AVG
AVG Should be considered an option for HD access in children especially who require replacement of native vessels to perform an adequate anastamosis
Alternative materials:
Saphenous vein
Bovine
Umbilical
Darcon
Polyurethane, cryopreserved femoral vein
Polytetrafluorethylene (PTFE) is most commonly used

18. One study compare bovine with PTFE graft demonstrated fewer complications with PTFE ones:
- Lower infections
- Lower thrombosis
- Easier to obtain and easier to repair
Graft are most commonly placed in forearm between brachial artery & basilic to brachial vein.
The thigh can be used femoral artery and saphenous to femoral vein in small children
-Higher infection rates been noted with thigh graft than with upper extremity grafts

19. High primary potency rate Ease of technical creation
Advantage of AVG
Shorter time to use
High primary potency rate
Ease of technical creation
Sheath et al reported creation of 24 AVF and 28 AVG respectively .
The most common site of AVG is the thigh -50% of patients
Disadvantages of AVG
Thrombosis
Stenosis
Infection
Sheath et al permanent vascular access survival in children and adolescent with end stage renal disease 2002 Kidney Int 62:

20. - Intervention rate 17.8% AVF compared to 33% of AVG
Ramage et al reported long term complications rate of AVF compare with AVG in retrospective study conducted over 20 years
- Intervention rate 17.8% AVF compared to 33% of AVG
Reason of discontinuation of AVG were:
1. Infection 20%
2. Thrombosis 73%
Chant et al evaluated dialysis adequacy , KT/V , URR, anemia management and albumin status based on vascular access. No difference between AVF & AVG
Possible Complications of graft
1. Thrombosis
2. Stenosis
3. Infection
4.Steal syndrome
Ramage et al Vascular access survival in children and young adults receiving long term hemodilaysis 2005 AJKD 45:
Chant et al Comparison of vascular access type for pediatric HD with respect to urea clearance, anemia management, & serum albumin conc AJKD 45:

21. COMPARISON BETWEEN AVF & AVG
Lower infection
Higher infection
Lower thrombosis rate
Higher thrombosis rate
May take 3-6 months to mature
Can be use within few weeks
Primary Failure rate is higher
Primary Failure is lower
Secondary Failure rate is lower
Secondary Failure rate is higher

22. CENTRAL VENOUS CATHETER
Central venous catheter are the most commonly used vascular access in children in north America data from USRDS 40% of children who were receiving chronic HD continued to use catheter
Data from ANZDATA 2008 showed the catheters were used exclusively below 10 years of age
NAPRTCS 2008
78% catheters
12% AVF
7% AVG
European Pediatric Dialysis Working Group
60% catheters
38% AVF
2%AVG

23. CENTRAL VENOUS CATHETER
First choice in patient require urgent HD
2. Stage V CKD
3. As abridge from a patient who is expected to receive planned transplant
4. Is training to transfer to PD
Advantage
- It can be used immediately
Disadvantage
1. Short life span
2. Thrombosis
3.Infection
4. Malfunction
5. Possible fibrin sheath formation
Median survival times of CVC is 4 months – 10.6 months

24. CENTRAL VENOUS CATHETER
Goldstein et al evaluated catheter survival time in 58 uncuffed & 22 cuffed CVCs
Median survival time of uncuffed catheter is 31 days and cuffed catheter is 123 days
1 year survival of long term cuffed catheter 27%
CVC in children whose vasculature is too small <10 kg, CVC may be the best temporary solution
Goldstein et al 1997 HD catheter survival and complications in children and adolescent pediatric nephrology 11: 74-77

25. Two questions to be answered:
What size of catheter to use?
Where to put it?

26. “Size matters!”

27. Q = ∆Pπr4 8l Pousielle’s law-
Smaller diameters offer greater resistance to flow
Longer lengths offer greater resistance to flow
Decreasing the diameter by 1/5th is the same as doubling the length (roughly a 2 French size difference)
Q = ∆Pπr4
8l

28. Catheter Specifications
French
Size 5 7 8 10 12
Flow Rate
(ml/min) ?
80-100

29. Catheter Specifications
French
Size 5 7 8 10 12
Diameter
(mm)
1.67
2.3
2.7
3.3
4.0

30. Vascular Access Central Venous catheter Cuffed catheter
Uncuffed catheter
size
Weight
type 8
Up to 20
Uncuffed catheter dual lumen 10
20-30
11.5
Above 30 7
20-40
Tesio Catheter
40-60 12
Above 60
Ash Split

31. Complications of CVC
USRDS data have shown sepsis rate with CVCs approximate 80/100 patient as compared to 10/100 patient for AVF
Potential sequences of CVC include:
- Septic shock
- Subacute bacterial endocarditis
- Osteomyelitis
- Epidural abscess
One study evaluated potential differences in infection rate based on use of three agents for exit site care
- 2% chlorhexidine found infection rate is 0.5%
- 10% povidine iodine found infection rate is 2.5%
- 70% alcohol found infection rate is 2.3%
Different antimicrobial catheter lock studies suggest that citrate is ideal

32. PROS AND CONS OF CENTRAL VENOUS CATHETER FOR HD IN CHILDREN
Easily placed
Infection rate high
Can be use immediately
Failure rate and replacement rate high
Painless to the patient
Blood flow rates are variable
Require little planning prior to placement
Permanent damage to central venous system (stenosis/thrombosis)
Easily removed if used as transitional access for future PD on transplant patients
Damage to central vessels can prohibit future AVF/AVG placement in ipsilateral extremity
No vascular Steal
Possible arrythmia
Decreased risk of high outpatient cardiac failure

33. Monitoring of vascular access
Goldstein et al described use of dilution technique on regular basis on pediatric patient population to date improve the life of access.
Use of ultrasound 50% reduction in number of hospitalized patient.
This further supported by NFK/K-DOQI guidelines for pediatric vascular access .
Based on review of current literature the authors would propose the following as tools for ongoing monitoring of AVFs and AVGs.

34. Access Monitoring
1. Inspection: the access should be assessed weekly through inspection, palpation, and auscultation by the nursing staff.
- With specific attention to arm swelling.
- Prolonged bleeding after needle removal.
- Change in thrills or bruits.
-The nephrologist should inspect the access at each physical examination.
2. Surveillance ↓KT/V or URR. Determination of access recirculation should be documented on a monthly basis.
Ultrasound dilution/month if not available do Doppler U/S /month.

35. Access Monitoring
3. Referral: Fistulogram with possible angioplasty if:
- Inadequate blood flow comprising adequacy.
- Elevate access recirculation >20% after needle connection.
- Corrected access flow less than 650ml/min/1.73m2 by U/S dilution.
- Consistent abnormality on Doppler U/S.
-Pseudoaneurysm has formed, rotation of puncture site can help minimize risk of pseudoaneurysm.

36. Hemodialysis Prescription
Hemodialysis Equipment:
Tubing
Dialyzer
Dialysis Machine
Tubing:
Total
Arterial (ml)
Venous (ml)
Pt. weight
Tubing 29 8 21
<6 kg
Mini Neonatal 40 18 22
6-12 kg
Neonatal 72 30 42
>12 kg
Pediatric
132 60 70
>30 kg
Adult

37. Types of Dialyzer Dialyzer: Types of Membrane Blood volume capacity
Service area
UF coefficient
Clearance of various substances
Sterilization

38. Hemodialysis Prescription
Types of Dialyzer
Low flux (KUF <10 ml/hr/mmHg)
High flux KUF ml/mmHg
Hallow fiber (capillary)
Parallel Plate
Types of Membranes
Unmodified cellulose low flux
Modified cellulose (Low & high flux)
Synthetic (low & high flux)
Synthetic noncellulose membranes are more biocompatible, size of dialyzer shouldn’t exceed % of patient service area

39. Selection of Dialyzer that can be used in children
Surface Area
(m2)
Fill Volume
(ml)
UF Coefficient
(ml/min/mmHg)
Gambro Polyflux 14L
1.3 77
9.5
Polyflux 17L
1.7
103
12.5
Polyflux 11S
1.1 81 53
Polyflux 14S
1.4
102 62
Polyflux 17S
121 71
2H (HF)
0.2 17 15
6H (HF)
0.6 52 33
Fresenius F3
0.4 28
F4 HPS
0.7 42
4.3
F5 HPS
1.0 63
6.2
F6 HPS 82
8.5
F7 HPS
1.6
9.8
F8 HPS
1.8
114
11.1
Xenium (HF) 69 49
130 (HF) 78
150(HF)
1.5 91
210(HF)
2.1
126 80
Baxter CA-50 (LF)
0.5 35
2.5
FB 110GA 65
8.1

40. Hemodialysis Prescription con’t.
Dialysis Machine:
Precise control of UF, volumetric assessment
Capable of low blood flow speeds
Ability to use lines of varying blood volume
Measure removal of very small amount of fluids
Continuous blood volume monitoring

41. Hemodialysis Prescription
Blood Flow rate
1st session 90 ml/m2
2-3 ml/kg/min
Latter
5-7 ml/kg/min ml/m2
Dialysate: It compose
Treated water
Electrolytes Na 140 mmol/L, K 2-3 mmol/L. Cl meq/L, HCO3 40 meq/L, Mg meq/L, Ca mmol/L
Acid Buffers
Glucose 100 g/L
Dialysate Flow rate 2 times more than blood flow rate, standard 500 ml/min
UF: Standard weight % of BW/hr. not more than 5% BW/HD session

42. Hemodialysis Prescription cont.
Anticoagulation
Heparin loading – 2000 IU/m2
20 IU/kg
10 IU/kg in infant
Maintenance – 400 IU/m2
10-20 IU/kg to be discontinued 30 minutes prior to the end of dialysis
aPTT or more than 50% above baseline of ACT
Heparin lock: with concentrated heparin 50 U/kg/lumen for weight less than
10 kg
1000 U/ml BW (10-20 kg)
2500 U/ml BW>20 kg

43. Hemodialysis Prescription Components
Comments
Blood Line
Pediatric/Neonatal according to the patient’s size
Dialyzer Size
The size of the dialyzer should not exceed
75-100% of the patient SA
Blood-flow rate
90mL/m2/min to maximum of ml/m2/min*
Dialysate-flow rate
500 ml./min is the standard, may vary ml/min
Dialysate Composition* Sodium
Potassium
Bicarbonate
Calcium
140 mmol/l
2-3 mmol/l
40mEq/l
mmol/L
Ultrafiltration Rate
1.5 to 2% of body weight/hr and not more than 5% body weight/dialysis session*
Anticoagulation
Heparin is the standard; Loading dose 2000 IU/m2 followed by 400 IU/m2/hr*
Treatment duration and Frequency of Hemodialysis Sessions
Three sessions per week for 3 to 4 h per session to achieve the minimum target prescription of 1.2 to 1.4 Kt/V

44. Hemodialysis Adequacy
Hemodialysis adequacy: Minimum adequate dose of HD given 3/times/week to patient with Kr less than 2ml/min/173m2, spkt/v 1.2/dialysis
URR of 65%
Target dose HD 3 times/week
spkt/v 1.4/dialysis not including residual kidney function
URR 70% single port kt/v

45. Methods of Measurement of Delivered Dose of Hemodialysis
Single-pool Kt/V calculated by Daugirdas II Formula
Equation I:
spKt/V = - In (C1/C0 – x t) + (4 – 3.5 x C1/C0) x UF/W
Equilibrated kt/V
Equation II:
estBUN = ([BUN15min – BUN30secs]/0.69) + BUN30secs
KDOQI Guidelines 2006
Cherry Mammen, Goldstein White Standard kt/V threshold to accurately predict single pool kt/V target for children receiving thrice weekly maintenance HD. Nephrology Dialysis Transplant 2010

46. Methods of Measurement of Delivered Dose of Hemodialysis
Equation III:
cKt/V (Goldstein) = -1n (estBUN/CO – x t)+ (4-3.5 x estBUN/C0) x UF/W
Equation IV:
stdKt/V = 168 * [1-exp[-eKt/V]/t]/
[1 – exp [ - eKt/V]/spKt/V] + [168/(N * t) – 1]
Equation V:
URR = 100x(estBUN – BUN30secs)/ BUN30secs
Equation VI:
%UFF = 100 – [(pre-treatment weight – post-treatment weight)/post-treatment weight]
Cherry Mammen, Goldstein White Standard kt/V threshold to accurately predict single pool kt/V target for children receiving thrice weekly maintenance HD. Nephrology Dialysis Transplant 2010

47. Recommended Methods vs Treatment Type for 2-3 HD per week
For 2 or 3 dialysis Treatment per week
Single pool Kt/Vurea determined by:
Urea kinetic modeling
Simplified multivariable equation
Equilibrated Kt/V (eKt/V)
Bloodless measurements of dialyzer clearance using ionic conductance or dialysate urea monitoring URR
Double pool Kt/Vurea by formal kinetic modeling (used only for research purposes)
Solute removal index (SRI) from dialysate collections
For more frequent dialysis: a continuous equivalent of kidney clearance
Standard Kt/Vurea
Normalized Kt/Vurea

48. Maintaining Hemodialysis Adequacy
Preservation of residual renal function
Aggressive Management of HTN
Avoidance of Excessive UF
Avoidance of potential insults to RRF (contrast, medications, infection, volume, contraction)

49. Lower Kt/V causes If spKt/V is lower than expected: Blood flow rate
Duration of treatment
Dialysate flow
Dialyzer specification and KoA
Intradialytic hypotension
Undetected early termination of treatment
Was the anticoagulation adequate?
Was post dialysis blood sampling appropriate?
Was the needle size and placement appropriate and optimal?
Was the blood pump adequately calibrated?
Was the blood pump segment wrong?
Was parenteral nutrition infused during treatment?

50. Practical example of hemodialysis adequacy
nPCR
spKt/V
Weight (kg)
Month
1.20
1.40
34.3 1
1.15
1.32
35.2 2
1.18
36.1 3

51. Practical example of hemodialysis adequacy
nPCR
spKt/V
Weight (kg)
Month
1.20
1.40
34.3 1
0.90
1.32
35.2 2
0.65
36.1 3

52. Practical example of hemodialysis adequacy
nPCR
spKt/V
Weight (kg)
Month
1.05
1.40
34.0 1
0.95
1.32
32.5 2
0.88
1.45
31.3 3

53. Anemia Management in ESRD in children
Hb g/dl
Serum ferritin target level >100 mg/ml
Tsat >20%
Monthly (CBC & reticulocyte count)
Every 3/12 serum ferritin, serum Tsat and serum iron.
with change therapy CBC weekly for 6/52

54. Initial dosing of HD below 5 years 250-300 unit/kg/week)
Eryhtropoetin
Initial dosing of HD below 5 years unit/kg/week)
Above 5 years units/kg/week
Darbapoetin 0.45 – 0.75 mcg/kg/week
IF Hb above target level or increase by 1.3 g/dl in 2 weeks decrease 25% of ESA
IF Hb increase g/dl isn’t achieved over 8 weeks increase ESA by 25%
Iron
Iron dextran need test dose because of anaphylaxis
Iron gluconate, sucrose. No need for test dose
KDOQI Guidelines 2006

55. Bone Mineral Management in ESRD
Serum phosphorus
Children 1-12 years 4-6 mg/dl ( mmol/L)
Children over 12 years – mg/dl ( mmol/L)
Serum calcium
mg/dl
mmol/L
Ca x phosphate products should be less than 5 mmol/L
Total eliminated Ca should not exceed 2500 mg/day
Metabolic acidosis HCO 22 mmol/L
KDOQI Guidelines 2006

56. Bone Mineral Management in CKD
Target serum PTH
GFR Range
(ml/min/1.73 meter square)
CKD stage
35-70 PG/ml, pmol/l
60-89 2
35-70 pg/ml, pmol/l
30-59 3
pg /ml, pmol/l
15-29 4
pg/ml, pmol/l
<15 or dialysis 5

57. Bone Mineral Management in CKD
PTH, alkaline phosphatase
Calcium, PO4, total CO2
GFR
Stage
At least yearly
60-89 2
At least every 6 months
30-59 3
At least every 3 months
15-29 4
At least every month
<15 or dialysis 5

58. Nutritional Status
Phosphorus – CKD 3 – 5 and 5D decrease dietary phosphate to 80% of DRI for age when PTH above target range of CKD and phosphate exceed normal reference
Protein – dietary protein of daily protein requirement for CKD 3-5
Carbohydrate: Normal carbohydrate compare to age match healthy child
Vitamins – B1, B2, B3, B5, B6, B8, B12, vitamin C, A, K, folic acid, copper, zinc should be 100% of daily requirement
Trace elements 100% if clinical evidence of deficiency
Free water & Na supplementation should be consider for polyuric child.
Na supplements should be consider for all infants in PD due to substantial loss even anuric and to be restricted for hypertensive child
Potassium should be restricted for CKD 2-5
Acidosis is to be corrected to HCO3 22 mmol/l
KDOQI Guidelines 2006

59. Nutritional Status Growth
Growth hormone CKD 2-5 for short stature or height /age <3rd centile persist for 3 months despite adequate nutritional treatment and correction of metabolic abnormalities
Calories should be 100% maintaining its chronological age

60. Complications During Hemodialysis
Disequilibrium symptoms – movement of water to brain cell by osmosis due to sudden drop of urea in plasma
Presentation: Nausea, headache, dizziness and seizure, coma
Treatment: Blood flow, dialyzer, duration of treatment
Mannitol of infusion 1g/kg over 1 h
1st session 30% drop, increase 50%, target 70-75% urea reduction
Ct/C0 = e –kt/V
Ct urea after t minutes of dialysis
C0 urea at initiation of dialysis
K – specific dialyser urea clearance ml/min
V = Patient urea volume of distribution

61. Complications During Hemodialysis
Hypotension:
Intravascular volume depletion due to slow refiling from extravascular space
Use of dialysate Na lower than plasma
Exchanging UF
Impaired sympathetic activity
Warm dialysate – vasodilation
Splanching pooling of blood while eating during dialysis
Use of antihypertensive medication on day of dialysis
Treatment:
NS 5 ml/kg
Cessation of UF
Reassessment of target eight daily fluid allowance review
Separate UF from dialysis
Na ramping
Hct monitoring

62. Complications During Hemodialysis
Intradialysis hemolysis
Symptoms: Pain & nausea
Presentation: Dark appearance to venous blood due to over heating, contamination, hypertonicity of dialysate, kinking of line, malfunctioning of pump
Treatment: Stop dialysis, check potassium
Urticaria: antihistamine or hydrocort
Air embolism: rare as air detection will clamp the return line 1 ml/kg
Symptoms: Seizure, coma, chest symptoms
Treatment: Clamp lines, stop pump, put head down, give 100% oxygen
Air may need to be aspirated from ventricles

63. Complication Post-Dialysis
Malnutrition is common is children receiving hemodialysis. The risk of death is reported:
54% for each 1 g/dl fall in albumin
57% reduced if serum albumin >4g/dl
14% increased with each decrease of one height of standard deviation score below normal at start of dialysis
Neuropsychologial outcomes: One study showed children below 18 months have:
42% neuropsychological impairment
58% attend regular school

66. Social & Psychological Issues
Dialysis Unit
Vacation
School
Economic status
Transfer of Service

67. Complication Post-Dialysis
Renal osteodystrophy
Cardiovascular Disease
Hypertension – in one case series 624 children in HD 79% of them was with hypertension and with 62% receiving antihypertensive medications
Left ventricular hypertrophy up to 80%

68. Mortality
Mortality risk in children in dialysis is >30 times higher than age and gender match normal children
US 5 years survival of 2867 patient starting dialysis at age 1, 1-5, and >5 years was 60, 80, and 85%
ANZATA- RRT demonstrated a 10 years and 20 years survival 79% and 66%.
Mortality is higher in children in dialysis and less post transplant as noted by ANZATA
UK Network 10 fold higher risk of death in children on dialysis compared to those were transplanted
Cause of Death is CVD 1000 fold higher in young adults on dialysis than age match normal
USRDS – 22.5% of death due to CVD
ANZATA 45% of death due to CVD
Dutch 41% of death due to CVD

69. Mortality Age at start of dialysis
NAPRTCS report lower survival for children who begin HD before 1 year of age with survival rate of 82, 73 63% at 1, 2, 3 years after initiation of dialysis.
Comparison of survival between Hemodialysis and PD
Italian registry showed no difference between years but below 5 years who were most exclusively managed by PD had a poorer 5 years survival
USRDS showed no difference in 5 years survival between PD and hemodialysis at any age

70. Mortality
2013 USRDS Annual Data Report, Pediatric ESRD volume 2

71. Mortality
2013 USRDS Annual Data Report, Pediatric ESRD volume 2

72. Mortality
2013 USRDS Annual Data Report, Pediatric ESRD volume 2

73. Mortality
2013 USRDS Annual Data Report, Pediatric ESRD volume 2

74. Summary of Hemodialysis in Children
Although principles of hemodialysis are similar for adult and children there are fundamental differences in technical aspect of procedures and complications
Optimal care is provided by multidisciplinary team (Pediatric Nephrologist, skilled nurses, dietician, vascular access coordinator, vascular surgeon, radiologist, psychologist, and social worker)
Good vascular access is essential for the success of hemodialysis
Hemodialysis equipment must be modified for pediatric patient
Long-term quality of life is lower in children on dialysis compared with normal healthy control and children receiving renal transplant

75. Thank You Clinical Guidelines for Hemodialysis Centers
in The Kingdom of Saudi Arabia
Thank You