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| My members |
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| National kidney foundation |
Date: 3th Octorber 2011
Hospital: Pusat Dialisis NKF – Good Health,27, Lorong 1, Kampung Pandan 55100 Kuala Lumpur
Supervisor: Dr / MA / SN / RPh: SN Sariah Bt Husein
General briefing on procedure of haemodialysis / peritoneal dialysis:
Observe / take note on:
- Vascular access
The supervisor told us that a vascular access is the insertion of a flexible thin plastic tube via needle into a blood vessel to provide an effective method of drawing blood for purification before reinserting the blood back into vessels. The supervisor also told us that in order to facilitate the purification of blood ,arteriovenous fistula surgery can be done .In this surgery, an artery and a vein are joined together through anastomosis. Since this bypasses the capillaries, blood flows rapidly through the fistula from artery to vein in which blood mixture is withdrawn and purified. This provides a chance for the blood from artery to be purified without puncturing the artery. This reduces the dangers of haemodialysis, because if the blood from artery is to be drawn out directly from artery it will be painful and dangerous due to the high blood pressure in artery.
- Dialysers
The supervisor told us that the type of dialyser used in her centre is known as F8 types dialyser. These dialysers are also known as kidneys. The dialyzer consists of a plastic device with the facility to perfuse blood and dialysate compartments at very high flow rates. The surface area of modern dialysis membranes in adult patients is usually in the range of 1.5–2.0 m2. These dialyzers are composed of bundles of capillary tubes through which blood circulates while dialysate travels on the outside of the fiber bundle.There are four categories of dialysis membranes: cellulose, substituted cellulose, cellulosynthetic, and synthetic. Over the past three decades, there has been a gradual switch from cellulose-derived to synthetic membranes, this is because synthetic membranes, such as polysulfone, polymethylmethacrylate, and polyacrylonitrile membranes, does not have the presence of hydroxyl group and so is more biocompatible .We also observed that each patient in the centre has their own dialyser with their own name labelled on it. The supervisor also told us that these hemodialysers are to be reprocessed and reused (the details will be discussed by me later).
3. Dialysate :
Dialysate is the solution consisting of essential ions like potassium ,calcium, sodium, magnesium, acetate ion and of course the purified and softened water. The potassium concentration of dialysate may be varied from 0 to 4 mmol/L depending on the predialysis plasma potassium concentration. Wherease , the usual dialysate calcium concentration in U.S. hemodialysis centers is 1.25 mmol/L (2.5 meq/L). The usual dialysate sodium concentration is 140 mmol/L. These concentration should be maintained critically ,otherwise problem like cardiac arrhythmias . Besides that if the sodium concentration provided is too low then the patient may in the risk of getting muscle cramp and hypotension. These ions will move from dialysate into patient blood via the process of passive diffusion.
- Anticoagulant used
The anticoagulant is used to prevent the clotting of the blood during dialysis process. But the side effect of heparin involves hyperlipidemia. So drug like statins is prescribed to lower down the cholesterol and lipid level in patient body. Saline is also used sometime in replace of heparin ,this is usually done when the patient has a wound on body or when patient just underwent a surgery.
- Characteristics of patients undergoing HD / PD
The patients all look restless, tired, and weak. The supervisor told us that this is because of the diet restriction. The diet restriction is to control ions profile of patient blood. For example patient is not encouraged to take food high in phosphate.
Besides that we also observed that patients have swelling on their sites of haemodialysis where the needles punctured into their skin. This is due to inflammation. The supervisor told us that the site of haemodialysis should be covered by clean thick cotton as long as the needle has penetrated in their skin. This is to prevent any infections and to prevent the entering of air into the site of injection, worsening the swelling at the site of haemodialysis.
- Preparation before HD / PD
The dialyser is cleaned with hydrogen peroxide and peroxyacetate acid. This is to kill the microorganisms and bacterial. Besides that dialysers is also cleaned by the process of reverse ultrafiltration On the other hand, machine compartments are cleaned with concentrated bleach. The water used for haemodialysis need to be pre-treated, filtered , deionized, and soften. We also visited to the filtering room. Which consists of multimedia filter chambers, which are responsible in removing of small particles, besides that carbon filters chambers also play an important role in removing chlorine in the water. Softerner chambers play a role in removing of ions like calcium and magnesium. We also saw two indicators which labelled as “sample accepted” and “sample rejected”. Both of these indicators have their respective bubbles in them, and they are level most of the time. The supervisor told us that sometimes if they need to save water they can actually increase the bubble level of the indicator labelled with ”sample accepted” , so that the water saving process become more effective. These filters and chambers need to be checked from time to time in case they is any leakage, and the flow rate and pressure of the water in the chambers need to be controlled accordingly as well. The supervisor also told us that patient blood pressure, heart rate, physiology condition as well as drugs taken need to be checked before starting haemodialysis. Let say in the case when the non-hypertensive patient blood pressure increases, the supervisor will decrease the volume of water in the dialysate. On the other hand if patient blood pressure drops too low the supervisor will increase the amount of water in the dialysate. The drop in patient blood pressure can be due to haemodialysis itself, hypertensive drugs and even as simple as after taking meal. This can be overcome or prevented by not taking hypertensive drugs right before haemodialysis or patient can considered using short acting hypertensive drugs in replace for example metoprolol. The patient should also avoid taking heavy meal right before having dialysis, this is because after taking a heavy meal most of the blood may flow to small intestine for better absorption, so the centre vascular system has less blood now, thus blood pressure of patient decreases. These measures are important because if patient undergoing haemodialysis is having very low blood pressure than the patient can easily be fainted due to hypotension.
The productivity and temperature of the haemodialysis need to be adjusted to proper value as well before the haemodialysis can be started. Flow rate, pressure, and conductivity of blood and dialysate need to be monitored over time as well. NaHCO3 is also added into the dialysate as phosphate binder of the blood.
- Duration of HD / PD
Duration of haemodialysis is 3 times per week, each time 4 hours. Duration of peritoneum dialysis is 3-4 times daily and each cycle takes about 1 hour. Supervisor told us that some people choose to have peritoneal dialysis instead of haemodialysis are because they are living too far from dialysis centre or they feel that haemodialysis is troublesome.
- Complications of HD / PD
The possible complications and site effects are hypotension, muscle cramp, anaphylactoid reactions, and cardiovascular diseases.
- Medications in patients undergoing HD / PD
The common drugs taken by patient undergoing HD and PD are calcium carbonate, calcitrol, vitamin B complex. Folic acid, ferrous fumerate, vitamin C ,and erythropoietin . If the patient is hypertensive then antihypertensive drugs like nifedipine, enalapril, and metoprolol can be given. Drug which can increase body immune system can also be given if the patient is having a low body immune system example having flu easily. Statins is also given to prevent hyperlipidemia secondary to heparins side effect.
For our patient, she is taking calcium carbonate, one alpha, betaloe, vitamin B complex, folic acid, ferrous fumerate, vitamin C ,erythropoietin, and metoprolol.
Calcium carbonate is a phosphate binder which decreases the level of phosphate ions in the blood. This will latter increase the level of free calcium ions in the blood. The dose prescribed to her is 5 tablets per day, each tablet 1500mg, and is to be taken with meals. It is taken together with meals in order for them to bind effectively with phosphate ions in the food, thus reducing the absorption of phosphate ions into the blood stream. Besides that she is also taking one alpha which is a calcitrol /vitamin D drugs. This drug is given to increase the absorption of calcium ions from the guts. The dose prescribed to her is 0.5gm twice per day and is to be taken with meal. Both of these drugs aiming to increase calcium level in blood and to prevent the happen of osteoporosis as well as osteodystrophy. But these drugs must not be taken together because calcium carbonate can affect the effect of calcitrol. The blood calcium and phosphorus ions level are to be checked and monitored every time. The blood test is to be conducted every 3 months. Vitamin B complex (500mg/tablet), folic acids(0.5mg/tablet), erythropoietin (eprex) and ferrous fumerate(500mg/tablet) are given to her to treat anaemia secondary to chronic kidney failure. The doses given are 1 tablet per day for vitamin B complex, folic acid and ferrous fumerate. Wherease the dose for erythropoietin is 3000mg 3 times per week via subcutaneous or intravenous injection. Usually ferrous is given only when the erythropoietin level in body is enough. Betaloe(50gm twice daily) and vitamin C (30mg once daily)are given to boost up the immune system of patient so that patient does not get flu so easily. Betaloe is also known as Beta-1, 3-D glucan and it is derived from the cell walls of baker’s yeast, it works by binding to the cell membrane of white blood cells(neutrophils, T cells, lymphocytes…) and activating them. Besides that the vitamin C given also increases the absorption of iron supplement. This is because iron is best absorbed in acidic condition. But it may cause gastric, so usually iron is taken after meal ,and it is important not to take iron together with calcium carbonate since the drug interaction between two may decrease the effects of them. Metoprolol(100mg once daily) is given to this patient as well, this is because our patient is suffering from hypertension. Supervisor told us that metoprolol is choosen over other antihypertensive drugs because it is cheap and able to reduce the risk of getting cardiovascular disease secondary to haemodialysis , this is because metoprolol is a good beta1 receptor antagonist drug. The other advantages of metoprolol is it does not cause muscle contraction problem .The dose given is 1 tablet daily. And we also realized that two types of metoprolol are there, one is short acting and the other is long acting metoprolol. The short acting one is only to be taken when the patient is preparing for a haemodialysis, this is to prevent hypotension during haemodialysis .All the drugs discussed above are in tablets dosage form except for eprex which is in an injection form. Last time our patient is given with nifepidine(calcium channel blocker) but this drug is stopped on January 2011 and replaced with metoprolol for the reasons stated above (eg: it does not cause muscle contraction problem ).
Interview a patient on haemodialysis
Initials: ENM Age :80yo Gender :Female Race :chinese
Current medical problems:
Hypertension(47yo) and chronic renal failure(76yo)
Past medical history:
Hypertension since the year of 47
Presence of signs & symptoms of renal failure | Yes / No | Significant lab tests (the most recent lab test) | Value |
Ankle oedema | no | Serum creatinine: | 682micromol/l |
Skin excoriation/ pruritus | no | Creatinine clearance: | 5ml/min (eGFR) |
“Brown line” pigmentation of nails | no | Serum urea: | 19.9mmol/l |
Bruising | no | Random / fasting blood glucose: | - |
Jaundice | no | Serum potassium: | 4.7 mmol/l |
Muscle wasting or emaciation | no | Serum sodium: | 138 mmol/l |
Nausea / vomiting | no | Serum calcium: | 2.22 mmol/l |
Fatigue / tiredness | yes | Serum phosphate: | 1.09 mmol/l |
Haemoglobin: | 10.7 mmol/l |
Reason for dialysis: Chronic kidney failure
Undergoing dialysis since: 5/2007
Frequency of dialysis: 3 times per week each time 4 hours
Dialysis-related complications that the patients has experienced: fatigue, swelling at the site of injection.
Current Medication (Write the complete regimen) | Indication | Dose Check (Fill in if the dose given is not appropriate) |
Calcium carbonate 1500mg, 5times daily, take nwith meal | Phosphate binder to decrease the absorption of phosphate ions and increase free calcium level in blood | - |
One alpha 500mg, twice daily | Calcitol, increase the absorption of calcium ions in the blood. | - |
Vitamin B complex 500mg, once daily | Increase the red blood cells level back to normal, and prevent severe anaemia. This is done by increasing the production of haemoglobins. | - |
Folic acids 0.5mg, once daily, | Increase the red blood cells level back to normal, and prevent severe anaemia. This is done by increasing the production of haemoglobins. | - |
Ferrous fumerate 500mg, once daily,, to be taken after meal | Increase the red blood cells level back to normal, and prevent severe anaemia. This is done by increasing the production of haemoglobins. | - |
Eprex (erythropoientin) 3000mg three times per week | It is a kind of hormones. When given subcutaneously or intravenously will increase the red blood cells level back to normal, and prevent severe anaemia. This is done by increasing the production of haemoglobins. | - |
Vitamin C 30mg once daily ,taken together with Ferrous fumerate | Increase the absorption of iron supplement and increase body immune system. | - |
Betaloe 50gm once daily | Boost up body immune system | - |
Metoprolol. Short acting and long acting. Both 100mg, once daily | Antihypertensive. | - |
· Identify common side effects.
Commmon side effects of :
calcium carbonate - dry mouth, constipation, nausea and vomiting.
One alpha-allergic, difficult breathing and uneven heart beats.
Betaloe-Aching ones, fatigue
Vitamin B complex-constipation, nausea and vomiting.
Folic acid-inflammation of digestive tract.
Ferrous fumerate- Constipation, stomach upset
Vitamin C- nausea and vomiting, diarrhea
Erthropoientin(eprex)- hypertension and thick blood.
Metoprolol- dizziness, drowsiness, fatigue, diarrhea
· Identify any clinically significant drug interactions.
Calcium carbonate is not to be taken together with either iron fumerate or calcitrol.
Because drug -drug interaction can occur, decreasing their respective effects.
· Which of these drugs may need dosage adjustment or dosage supplementation because of dialysis?
None of them..
· How does dialysis affect the patient’s life?
Patient has to spend their time on dialysis, and suffering from the pain of injection at the beginning of every dialysis injection.
Reflective diary
Date: 3th octorber 2011 Time:900am |
Today’s activities: NKF haemodialysis center visit |
A significant experience/observation today. I felt pity to those haemodialysis patient and this also inspired me to take more care of my kidneys and diets. |
Learning pearls from this experience/observation. I have learnt more about the haemodialysis machine, process, drugs used, as well as understanding CRD patient better. |
Additional learning needs from this experience/observation and my plan to achieve the learning. The budget of NKF for haemodialysis patient. |
Summary of what I have learnt. -As described on next page.- |
Meaningful interactions with health care team (preceptors, doctors, nurses, other health care students and peers). The supervisor is dedicated and knowledgeable., she explained well to us. |
Feelings and thoughts about today’s learning experience. I felt fulfilling after learning so many things. I am happy that I can see the things which I had learnt theoretically in the class. Feel like more practical. |
Summary on our visit and thins we learnt.
On 3th Octorber ,Monday , we visited to Good health NKF dialysis center.The person in charge is SN Sariah Bt Husein. She brief us well and she is experienced in handling haemodialysis. She told us that this center is a non government center and the funding is from public and NKF foundation. Last time the expenses for one haemodialysis cycle is around RM110(RM 50 is subsidized by NKF). But recently the expenses had increased to RM150 per haemodialysis. There are around 8 haemodialysis machine inside and the centre is clean, well facilitated,(toilet, air conditioner, televisions…) , the volunterrs thare are kind and hardworking.
Our patient is a 80 yo chinese women with CKF and she said that she had been drinking 6 cups of coffe per day without drinking plain water. She had been suffering from hypertension since the age of 47 and is recently(4years ago) diagnosed with chronic renal failure. Coffee and diuretics drugs have been found to be the culprits which overloaded her kidneys.
At the beginning the supervisor introduced us with what is meant by vascular access, she told us that a vascular access is the insertion of a flexible thin plastic tube via needle into a blood vessel to provide an effective method of drawing blood for purification before reinserting the blood back into vessels. The supervisor also told us that in order to facilitate the purification of blood ,arteriovenous fistula surgery can be done .In this surgery, an artery and a vein are joined together through anastomosis. Since this bypasses the capillaries, blood flows rapidly through the fistula from artery to vein in which blood mixture is withdrawn and purified. This provides a chance for the blood from artery to be purified without puncturing the artery. This reduces the dangers of haemodialysis, because if the blood from artery is to be drawn out directly from artery it will be painful and dangerous due to the high blood pressure in artery.
The supervisor also told us that the type of dialyser used in her centre is known as F8 types dialyser. These dialysers are also known as kidneys. The dialyzer consists of a plastic device with the facility to perfuse blood and dialysate compartments at very high flow rates. The surface area of modern dialysis membranes in adult patients is usually in the range of 1.5–2.0 m2. These dialyzers are composed of bundles of capillary tubes through which blood circulates while dialysate travels on the outside of the fiber bundle.There are four categories of dialysis membranes: cellulose, substituted cellulose, cellulosynthetic, and synthetic. Over the past three decades, there has been a gradual switch from cellulose-derived to synthetic membranes, this is because synthetic membranes, such as polysulfone, polymethylmethacrylate, and polyacrylonitrile membranes, does not have the presence of hydroxyl group and so is more biocompatible .We also observed that each patient in the centre has their own dialyser with their own name labelled on it. The supervisor also told us that these hemodialysers are to be reprocessed and reused (the details will be discussed by me later).
She said dialysate is the solution consisting of essential ions like potassium ,calcium, sodium, magnesium, acetate ion and of course the purified and softened water. The potassium concentration of dialysate may be varied from 0 to 4 mmol/L depending on the predialysis plasma potassium concentration. Wherease , the usual dialysate calcium concentration in U.S. hemodialysis centers is 1.25 mmol/L (2.5 meq/L). The usual dialysate sodium concentration is 140 mmol/L. These concentration should be maintained critically ,otherwise problem like cardiac arrhythmias . Besides that if the sodium concentration provided is too low then the patient may in the risk of getting muscle cramp and hypotension. These ions will move from dialysate into patient blood via the process of passive diffusion.
We also been taught that anticoagulant is used to prevent the clotting of the blood during dialysis process. But the side effect of heparin involves hyperlipidemia. So drug like statins is prescribed to lower down the cholesterol and lipid level in patient body. Saline is also used sometime in replace of heparin ,this is usually done when the patient has a wound on body or when patient just underwent a surgery.
The patients all look restless, tired, and weak. The supervisor told us that this is because of the diet restriction. The diet restriction is to control ions profile of patient blood. For example patient is not encouraged to take food high in phosphate.
Besides that we also observed that patients have swelling on their sites of haemodialysis where the needles punctured into their skin. This is due to inflammation. The supervisor told us that the site of haemodialysis should be covered by clean thick cotton as long as the needle has penetrated in their skin. This is to prevent any infections and to prevent the entering of air into the site of injection, worsening the swelling at the site of haemodialysis.
We also learnt about the preparations to be done by supervisor and volunteers before a patient start a dialysis. Supervisor said the dialyser is cleaned with hydrogen peroxide and peroxyacetate acid. This is to kill the microorganisms and bacterial. Besides that dialysers is also cleaned by the process of reverse ultrafiltration On the other hand, machine compartments are cleaned with concentrated bleach. The water used for haemodialysis need to be pre-treated, filtered , deionized, and soften. We also visited to the filtering room. Which consists of multimedia filter chambers, which are responsible in removing of small particles, besides that carbon filters chambers also play an important role in removing chlorine in the water. Softerner chambers play a role in removing of ions like calcium and magnesium. We also saw two indicators which labelled as “sample accepted” and “sample rejected”. Both of these indicators have their respective bubbles in them, and they are level most of the time. The supervisor told us that sometimes if they need to save water they can actually increase the bubble level of the indicator labelled with ”sample accepted” , so that the water saving process become more effective. These filters and chambers need to be checked from time to time in case they is any leakage, and the flow rate and pressure of the water in the chambers need to be controlled accordingly as well. The supervisor also told us that patient blood pressure, heart rate, physiology condition as well as drugs taken need to be checked before starting haemodialysis. Let say in the case when the non-hypertensive patient blood pressure increases, the supervisor will decrease the volume of water in the dialysate. On the other hand if patient blood pressure drops too low the supervisor will increase the amount of water in the dialysate. The drop in patient blood pressure can be due to haemodialysis itself, hypertensive drugs and even as simple as after taking meal. This can be overcome or prevented by not taking hypertensive drugs right before haemodialysis or patient can considered using short acting hypertensive drugs in replace for example metoprolol. The patient should also avoid taking heavy meal right before having dialysis, this is because after taking a heavy meal most of the blood may flow to small intestine for better absorption, so the centre vascular system has less blood now, thus blood pressure of patient decreases. These measures are important because if patient undergoing haemodialysis is having very low blood pressure than the patient can easily be fainted due to hypotension.
The productivity and temperature of the haemodialysis need to be adjusted to proper value as well before the haemodialysis can be started. Flow rate, pressure, and conductivity of blood and dialysate need to be monitored over time as well. NaHCO3 is also added into the dialysate as phosphate binder of the blood.
Other thing we learnt include the duration of dialysis , possible complications and side effect of dialysis as well as knowledge on the medication used by the patient there
Duration of haemodialysis is 3 times per week, each time 4 hours. Duration of peritoneum dialysis is 3-4 times daily and each cycle takes about 1 hour. Supervisor told us that some people choose to have peritoneal dialysis instead of haemodialysis are because they are living too far from dialysis centre or they feel that haemodialysis is troublesome.
The possible complications and site effects are hypotension, muscle cramp, anaphylactoid reactions, and cardiovascular diseases.
The common drugs taken by patient undergoing HD and PD are calcium carbonate, calcitrol, vitamin B complex. Folic acid, ferrous fumerate, vitamin C ,and erythropoietin . If the patient is hypertensive then antihypertensive drugs like nifedipine, enalapril, and metoprolol can be given. Drug which can increase body immune system can also be given if the patient is having a low body immune system example having flu easily. Statins is also given to prevent hyperlipidemia secondary to heparins side effect.
For our patient, she is taking calcium carbonate, one alpha, betaloe, vitamin B complex, folic acid, ferrous fumerate, vitamin C ,erythropoietin, and metoprolol.
Calcium carbonate is a phosphate binder which decreases the level of phosphate ions in the blood. This will latter increase the level of free calcium ions in the blood. The dose prescribed to her is 5 tablets per day, each tablet 1500mg, and is to be taken with meals. It is taken together with meals in order for them to bind effectively with phosphate ions in the food, thus reducing the absorption of phosphate ions into the blood stream. Besides that she is also taking one alpha which is a calcitrol /vitamin D drugs. This drug is given to increase the absorption of calcium ions from the guts. The dose prescribed to her is 0.5gm twice per day and is to be taken with meal. Both of these drugs aiming to increase calcium level in blood and to prevent the happen of osteoporosis as well as osteodystrophy. But these drugs must not be taken together because calcium carbonate can affect the effect of calcitrol. The blood calcium and phosphorus ions level are to be checked and monitored every time. The blood test is to be conducted every 3 months. Vitamin B complex (500mg/tablet), folic acids(0.5mg/tablet), erythropoietin (eprex) and ferrous fumerate(500mg/tablet) are given to her to treat anaemia secondary to chronic kidney failure. The doses given are 1 tablet per day for vitamin B complex, folic acid and ferrous fumerate. Wherease the dose for erythropoietin is 3000mg 3 times per week via subcutaneous or intravenous injection. Usually ferrous is given only when the erythropoietin level in body is enough. Betaloe(50gm twice daily) and vitamin C (30mg once daily)are given to boost up the immune system of patient so that patient does not get flu so easily. Betaloe is also known as Beta-1, 3-D glucan and it is derived from the cell walls of baker’s yeast, it works by binding to the cell membrane of white blood cells(neutrophils, T cells, lymphocytes…) and activating them. Besides that the vitamin C given also increases the absorption of iron supplement. This is because iron is best absorbed in acidic condition. But it may cause gastric, so usually iron is taken after meal ,and it is important not to take iron together with calcium carbonate since the drug interaction between two may decrease the effects of them. Metoprolol(100mg once daily) is given to this patient as well, this is because our patient is suffering from hypertension. Supervisor told us that metoprolol is choosen over other antihypertensive drugs because it is cheap and able to reduce the risk of getting cardiovascular disease secondary to haemodialysis , this is because metoprolol is a good beta1 receptor antagonist drug. The other advantages of metoprolol is it does not cause muscle contraction problem .The dose given is 1 tablet daily. And we also realized that two types of metoprolol are there, one is short acting and the other is long acting metoprolol. The short acting one is only to be taken when the patient is preparing for a haemodialysis, this is to prevent hypotension during haemodialysis .All the drugs discussed above are in tablets dosage form except for eprex which is in an subcutaneous or intravenous injection form. Last time our patient is given with nifepidine(calcium channel blocker) but this drug is stopped on January 2011 and replaced with metoprolol for the reasons stated above (eg: it does not cause muscle contraction problem ).
The workers there also told us on the side effects of these drugs and it is summarized as below:
Commmon side effects of :
calcium carbonate - dry mouth, constipation, nausea and vomiting.
One alpha-allergic, difficult breathing and uneven heart beats.
Betaloe-Aching ones, fatigue
Vitamin B complex-constipation, nausea and vomiting.
Folic acid-inflammation of digestive tract.
Ferrous fumerate- Constipation, stomach upset
Vitamin C- nausea and vomiting, diarrhea
Erthropoientin(eprex)- hypertension and thick blood.
Metoprolol- dizziness, drowsiness, fatigue, diarrhea
(Calcium carbonate is not to be taken together with either iron fumerate or calcitrol.
Because drug -drug interaction can occur, decreasing their respective effects.)
Overall, I felt fulfilling after learning so many things. I am happy that I can see the things which I had learnt theoretically in the class. Feel like more practical. After this visit I had learnt more about the haemodialysis machine, process, drugs used, as well as understanding CRD patient better now. I felt pity to those haemodialysis patient and this also inspired me to take more care of my kidneys and diets. I do not wish that I will suffer from the same disease in the future.
.
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