Kidney dialysis

Kidney dialysis[a] is the process of removing excess

water, solutes, and toxins from the blood in people Kidney dialysis
whose kidneys can no longer perform these functions
naturally. Along with kidney transplantation, it is a
type of renal replacement therapy.

Dialysis may need to be initiated when there is a

sudden rapid loss of kidney function, known as acute
kidney injury (previously called acute renal failure), or
when a gradual decline in kidney function, chronic
kidney failure, reaches stage 5. Stage 5 chronic renal Patient receiving hemodialysis
failure is reached when the glomerular filtration rate is Specialty Nephrology
less than 15% of the normal, creatinine clearance is ICD-9- 39.95 ([Link]
less than 10 mL per minute, and uremia is present.[1] CM m/[Link]?srchtype=procs&srcht
ext=39.95&Submit=Search&action=
Dialysis is used as a temporary measure in cases of
search)
acute kidney injury or for those awaiting kidney
transplant and as a permanent measure in those for MeSH D006435
whom a transplant is not indicated or not possible.[2]

In West European countries, Australia, Canada, the

United Kingdom, and the United States, dialysis is
paid for by the government for those who are
eligible.[3][4] The first successful dialysis was
performed in 1943.

Background
The kidneys have an important role in maintaining
health. When the person is healthy, the kidneys
Schematic of semipermeable membrane during
maintain the body's internal equilibrium of water hemodialysis, where blood is red, dialysing fluid is
and minerals (sodium, potassium, chloride, calcium, blue, and the membrane is yellow
phosphorus, magnesium, sulphate). The acidic
metabolism end-products that the body cannot get
rid of via respiration are also excreted through the kidneys. The kidneys also function as a part of the
endocrine system, producing erythropoietin, calcitriol and renin. Erythropoietin is involved in the
production of red blood cells and calcitriol plays a role in bone formation.[5] Dialysis is an imperfect
treatment to replace kidney function because it does not correct the compromised endocrine functions of
the kidney. Dialysis treatments replace some of these functions through diffusion (waste removal) and
ultrafiltration (fluid removal).[6] Dialysis uses highly purified (also known as "ultrapure") water.[7]
Principle
Dialysis works on the principles of the diffusion of solutes
and ultrafiltration of fluid across a semipermeable membrane.
Diffusion is a property of substances in water; substances in
water tend to move from an area of high concentration to an
area of low concentration.[8] Blood flows by one side of a
semipermeable membrane, and a dialysate, or special dialysis
fluid, flows by the opposite side. A semipermeable membrane
is a thin layer of material that contains holes of various sizes,
or pores. Smaller solutes and fluid pass through the
membrane, but the membrane blocks the passage of larger
substances (for example, red blood cells and large proteins).
This replicates the filtering process that takes place in the
kidneys when the blood enters the kidneys and the larger
substances are separated from the smaller ones in the
glomerulus.[8] A hemodialysis machine

The two main types of dialysis, hemodialysis and peritoneal

dialysis, remove wastes and excess water from the blood in
different ways.[2] Hemodialysis removes wastes and water by
circulating blood outside the body through an external filter,
called a dialyzer, that contains a semipermeable membrane.
The blood flows in one direction and the dialysate flows in
the opposite. The counter-current flow of the blood and
dialysate maximizes the concentration gradient of solutes
between the blood and dialysate, which helps to remove more
urea and creatinine from the blood. The concentrations of
Osmosis, diffusion, ultrafiltration, and
solutes normally found in the urine (for example potassium,
dialysis
phosphorus and urea) are undesirably high in the blood, but
low or absent in the dialysis solution, and constant
replacement of the dialysate ensures that the concentration of undesired solutes is kept low on this side of
the membrane. The dialysis solution has levels of minerals like potassium and calcium that are similar to
their natural concentration in healthy blood. For another solute, bicarbonate, dialysis solution level is set
at a slightly higher level than in normal blood, to encourage the diffusion of bicarbonate into the blood, to
act as a pH buffer to neutralize the metabolic acidosis that is often present in these patients. The levels of
the components of dialysate are typically prescribed by a nephrologist according to the needs of the
individual patient.

In peritoneal dialysis, wastes and water are removed from the blood inside the body using the peritoneum
as a natural semipermeable membrane. Waste and excess water move from the blood, across the visceral
peritoneum due to its large surface area and into a special dialysis solution, called dialysate, in the
peritoneal cavity within the abdomen.
Types
There are three primary and two secondary types of dialysis: hemodialysis (primary), peritoneal dialysis
(primary), hemofiltration (primary), hemodiafiltration (secondary) and intestinal dialysis (secondary).

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 hollow synthetic
fibers. The fiber wall acts as the semipermeable membrane. Blood flows through the fibers, dialysis
solution flows around the outside of the fibers, and water and wastes move between these two
solutions.[9] 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 solutes to move from blood to dialysate and allows the removal of several litres of excess fluid
during a typical 4-hour treatment. In the United States, hemodialysis treatments are typically given in a
dialysis center three times per week (due in the United States to Medicare reimbursement rules);
however, as of 2005 over 2,500 people in the United States are dialyzing at home more frequently for
various treatment lengths.[10] Studies have demonstrated the clinical benefits of dialyzing 5 to 7 times a
week, for 6 to 8 hours. This type of hemodialysis is usually called nocturnal daily hemodialysis and a
study has shown it provides a significant improvement in both small and large molecular weight
clearance and decreases the need for phosphate binders.[11] These frequent long treatments are often done
at home while sleeping, but home dialysis is a flexible modality and schedules can be changed day to day,
week to week. In general, studies show that both increased treatment length and frequency are clinically
beneficial.[12]

Hemo-dialysis was one of the most common procedures performed in U.S. hospitals in 2011, occurring in
909,000 stays (a rate of 29 stays per 10,000 population).[13]

Peritoneal dialysis
In peritoneal dialysis, a sterile solution containing glucose (called
dialysate) is run through a tube into the peritoneal cavity, the
abdominal body cavity around the intestine, where the peritoneal
membrane acts as a partially permeable membrane.

This exchange is repeated 4–5 times per day; automatic systems

can run more frequent exchange cycles overnight. Peritoneal
dialysis is less efficient than hemodialysis, but because it is carried
out for a longer period of time the net effect in terms of removal of
waste products and of salt and water are similar to hemodialysis.
Peritoneal dialysis is carried out at home by the patient, often
without help. This frees patients from the routine of having to go
to a dialysis clinic on a fixed schedule multiple times per week. Schematic diagram of peritoneal
Peritoneal dialysis can be performed with little to no specialized dialysis

equipment (other than bags of fresh dialysate).

Hemofiltration
Hemofiltration is a similar treatment to hemodialysis, but it
makes use of a different principle. The blood is pumped
through a dialyzer or "hemofilter" as in dialysis, but no
dialysate is used. A pressure gradient is applied; as a result,
water moves across the very permeable membrane rapidly,
"dragging" along with it many dissolved substances,
including ones with large molecular weights, which are not
cleared as well by hemodialysis. Salts and water lost from the
blood during this process are replaced with a "substitution
Continuous veno-venous haemofiltration
fluid" that is infused into the extracorporeal circuit during the
with pre- and post-dilution (CVVH)
treatment.
Hemodiafiltration
Hemodiafiltration is a combination between hemodialysis and
hemofiltration, thus used to purify the blood from toxins
when the kidney is not working normally and also used to
treat acute kidney injury (AKI).

Intestinal dialysis
In healthy humans, the intestines both remove uremic toxins
(urea, creatine, uric acid) from blood and add uremic toxins
(indoxyl sulfate, ammonia, etc.) to blood. More uremic toxins Continuous veno-venous
haemodiafiltration (CVVHDF)
are excreted through the gut (as feces) than through the
kidneys (as urine). This exchange of substances is enabled by
the massive surface area of the intestinal capillary network and intestinal mucus, together serving as a
large semipermeable membrane. In patients with kidney failure, the intestines receive a larger influx of
uremic toxins due to a higher concentration in blood, but this does not automatically translate to a benefit
in reducing blood toxin levels as gut bacteria use these toxins as food, producing more toxins in the
process. The goal of intestinal dialysis is to maximize the removal of uremic toxins into the intestines
while minimizing the production of new toxin molecules in the intestines. It serves as a more
conservative renal replacement therapy for those unable to tolerate conventional dialysis. There are a few
forms of intestinal dialysis:[14]

Small bowel/intestinal dialysis puts the dialysate in the small intestines through a surgical
opening (ileostomy), using the intestinal walls as the semipermeable membrane for
removing toxins. It did not show any actual survival benefit overall and was replaced by
modern dialysis methods.[14]
Induced diarrhea has been found to provide toxin removal in small, non-randomly controlled
studies. One method uses the ingestion of 1 to 1.5 liters of non-absorbable solutions of
polyethylene glycol or mannitol every fourth hour.[15]
Colonic dialysis puts the dialysate in the colon, which can be done without a surgical
opening: an anal catheter inserted through the anus can reach the ascending colon and
inject the dialysate there. The clinical use of colonic dialysis is still in its early stages (as of
2020), being studied mainly in Iran and China.[14][16]
Oral adsorbents are used in hope that they will absorb toxins as they pass through the gut.
One of them, AST-120, has undergone two multinational randomized controlled trials in
which it failed to show a benefit in slowing CKD progression. However, a post-hoc analysis
find some benefit in a subgroup of patients.[16]
A related development is supplementation with soluble fibres such as acacia fibre into the diet. These
fibers are digested by bacteria in the colon. This bacterial growth increases the amount of nitrogen that is
eliminated in fecal waste.[17][18]

Indications
The decision to initiate dialysis or hemofiltration in patients with kidney failure depends on several
factors. These can be divided into acute or chronic indications.
Depression and kidney failure symptoms can be similar to each other. It is important that there is open
communication between a dialysis team and the patient. Open communication will allow giving a better
quality of life. Knowing the patients' needs will allow the dialysis team to provide more options like:
changes in dialysis type like home dialysis for patients to be able to be more active or changes in eating
habits to avoid unnecessary waste products.

Acute indications
Indications for dialysis in a patient with acute kidney injury are summarized with the vowel mnemonic of
"AEIOU":[19]

1. Acidemia from metabolic acidosis in situations in which correction with sodium bicarbonate
is impractical or may result in fluid overload.
2. Electrolyte abnormality, such as severe hyperkalemia, especially when combined with AKI.
3. Intoxication, that is, acute poisoning with a dialyzable substance. These substances can be
represented by the mnemonic SLIME: salicylic acid, lithium, isopropanol, magnesium-
containing laxatives and ethylene glycol.
4. Overload of fluid not expected to respond to treatment with diuretics
5. Uremia complications, such as pericarditis, encephalopathy, or gastrointestinal bleeding.

Chronic indications
Chronic dialysis may be indicated when a patient has symptomatic kidney failure and low glomerular
filtration rate (GFR < 15 mL/min).[20] Between 1996 and 2008, there was a trend to initiate dialysis at
progressively higher estimated GFR, eGFR. A review of the evidence shows no benefit or potential harm
with early dialysis initiation, which has been defined by start of dialysis at an estimated GFR of greater
than 10 ml/min/1.732. Observational data from large registries of dialysis patients suggests that early start
of dialysis may be harmful.[21] The most recent published guidelines from Canada, for when to initiate
dialysis, recommend an intent to defer dialysis until a patient has definite kidney failure symptoms, which
may occur at an estimated GFR of 5–9 ml/min/1.732.[22]

Impact

Effectiveness
Even though it is not a cure for kidney failure, dialysis is a very effective treatment.[23] Survival rates of
kidney failure are generally longer with dialysis than without (having only conservative kidney
management). However, from the age of 80 and in elderly patients with comorbidities there is no
difference in survival between the two groups.[24]

Quality of life
Dialysis is an intensive treatment that has a serious impact on those treated with it. Being on dialysis
usually leads to a poor quality of life. However, there are strategies that can make it more tolerable.[25]
Receiving dialysis at home might improve people's quality of life and autonomy.[25]
Scheduling and adherence
Dialysis is typically on a regular schedule of three times a week.

Given that dialysis patients have little or no capacity to filtrate solutes and regulate their fluid volume due
to kidney dysfunction,[26] missing dialysis is potentially lethal. These patients can be hyperkalaemic
leading to cardiac dysrhythmias and potential cardiac arrest,[27] as well as fluid in the alveoli of their
lungs which can impair breathing.[28]

Some medications can be used in the short term to decrease serum potassium and stabilise the cardiac
muscle so as to facilitate stabilisation of acute patients in the setting of missed dialysis. Salbutamol and
insulin can decrease serum potassium by up to 1.0mmol/L each by shifting potassium from the
extracellular space into the intracellular spaces within skeletal muscle cells, and calcium gluconate is
used to stabilise the myocardium in hyperkalaemic patients, in an attempt to reduce the likelihood of
lethal arrhythmias arising from a high serum potassium.[29]

Survival without dialysis

People who decide against dialysis treatment when reaching end-stage chronic kidney disease could
survive several years and experience improvements in their mental well-being in addition to sustained
physical well-being and overall quality of life until late in their illness course. However, use of acute care
services in these cases is common and intensity of end-of-life care is highly variable among people opting
out of dialysis.[30][31]

Life Expectancy After Starting Kidney Dialysis

Life expectancy after starting kidney dialysis for end-stage kidney disease (ESKD) varies significantly
based on factors such as age, comorbidities, dialysis modality, and access to healthcare. Dialysis extends
life compared to untreated ESKD but does not restore normal kidney function. Median survival is
approximately 3–5 years, with 5-year survival rates around 35–42% for hemodialysis (HD)
patients.[32][33] Mortality is highest in the first year (15–20%), primarily from cardiovascular events or
infections.

Overall survival
For incident dialysis patients (mean age ~65 years), median survival is about 3 years, with adjusted
mortality rates of 187.7 per 1,000 patient-years.[32][34]

1-year survival: 80–85% overall; 60–70% for patients ≥65 years.[35] 3-year survival: ~57% for HD,
~68% for peritoneal dialysis (PD).[36] 5-year survival: 35–42% for HD; PD outcomes converge long-
term.[32][37]

Survival by age
Survival rate of dialysis patients drops significantly with their age. Peritoneal dialysis has a little better
outcome than hemodialysis, particularly for older patients.[38]
 survival rate (%)
Age group Modality
1 year 3 year 5 year 10 year

hemodialysis 92 80 70
<45
peritoneal 94 82 72

hemodialysis 88 70 55
45–64
peritoneal 90 74 58
hemodialysis 82 57 40
65–74
peritoneal 85 62 45

hemodialysis 70 37 20
75–84
peritoneal 75 45 28

hemodialysis 50 15 5
85+
peritoneal 60 25 10

For a 55-year-old, expected survival is ~5 years on dialysis vs. 26 years in the general population.[32][39]

Patients ≥80 years have ~50–60% 1-year survival with planned HD starts.[37]

Dialysis modality
Hemodialysis (HD): Used by ~88% of patients; 5-year survival ~40%. Higher early mortality from
urgent starts.[32] Peritoneal dialysis (PD): Better early survival due to home-based flexibility; outcomes
equalize after 2–3 years. May improve quality of life short-term.[36][40] Exceptional cases survive 20–30+
years with optimal care.[41]

Factors affecting survival

Positive factors
Younger age, fewer comorbidities, good nutrition (higher BMI/albumin), planned dialysis start, home
therapies.[42]

Negative factors
Diabetes, cardiovascular disease, urgent initiation, inadequate dialysis (Kt/V <1.2), infections. COVID-19
increased mortality in 2020 but rates declined by 2022.[32][43]

In low-resource settings, median survival may be ~1.5 years due to access barriers.[41]
Comparison to alternatives
Kidney transplantation offers superior survival (~80% at 5 years) and is recommended when
eligible.[44] For frail elderly patients, conservative management without dialysis may yield similar
survival but better quality of life.[39][45]

Pediatric dialysis
Over the past 20 years, children have benefited from major improvements in both technology and clinical
management of dialysis. Morbidity during dialysis sessions has decreased with seizures being exceptional
and hypotensive episodes rare. Pain and discomfort have been reduced with the use of chronic internal
jugular venous catheters and anesthetic creams for fistula puncture. Non-invasive technologies to assess
patient target dry weight and access flow can significantly reduce patient morbidity and health care
costs.[46] Mortality in paediatric and young adult patients on chronic hemodialysis is associated with
multifactorial markers of nutrition, inflammation, anaemia and dialysis dose, which highlights the
importance of multimodal intervention strategies besides adequate hemodialysis treatment as determined
by Kt/V alone.[47]

Biocompatible synthetic membranes, specific small size material dialyzers and new low extra-corporeal
volume tubing have been developed for young infants. Arterial and venous tubing length is made of
minimum length and diameter, a <80 ml to <110 ml volume tubing is designed for pediatric patients and a
>130 to <224 ml tubing are for adult patients, regardless of blood pump segment size, which can be of
6.4 mm for normal dialysis or 8.0mm for high flux dialysis in all patients. All dialysis machine
manufacturers design their machine to do the pediatric dialysis. In pediatric patients, the pump speed
should be kept at low side, according to patient blood output capacity, and the clotting with heparin dose
should be carefully monitored. The high flux dialysis (see below) is not recommended for pediatric
patients.[46]

In children, hemodialysis must be individualized and viewed as an "integrated therapy" that considers
their long-term exposure to chronic renal failure treatment. Dialysis is seen only as a temporary measure
for children compared with renal transplantation because this enables the best chance of rehabilitation in
terms of educational and psychosocial functioning. Long-term chronic dialysis, however, the highest
standards should be applied to these children to preserve their future "cardiovascular life"—which might
include more dialysis time and on-line hemodiafiltration online hdf with synthetic high flux membranes
with the surface area of 0.2 m2 to 0.8 m2 and blood tubing lines with the low volume yet large blood
pump segment of 6.4/8.0 mm, if we are able to improve on the rather restricted concept of small-solute
urea dialysis clearance.[48]

Dialyzable substances

Characteristics
Dialyzable substances—substances removable with dialysis—have these properties:
 1. Low molecular mass
2. High water solubility
3. Low protein binding capacity
4. Prolonged elimination (long half-life)
5. Small volume of distribution

Substances
Ethylene glycol
Procainamide
Methanol
Isopropyl alcohol
Barbiturates
Lithium
Bromide
Sotalol
Chloral hydrate
Ethanol
Acetone
Atenolol
Theophylline
Salicylates
Baclofen

Dialysis in different countries

United Kingdom
The National Health Service provides dialysis in the United Kingdom. In 2022, there were more than
30,000 people on dialysis in the UK.[25]

For people who need to travel to dialysis centres, patient transport services are generally provided without
charge. Cornwall Clinical Commissioning Group proposed to restrict this provision to people who did not
have specific medical or financial reasons in 2018 but changed their minds after a campaign led by
Kidney Care UK and decided to fund transport for people requiring dialysis three times a week for a
minimum or six times a month for a minimum of three months.[49]

Home dialysis
UK clinical guidelines recommend offering people a choice regarding where they get their dialysis.[25]
Research in the UK found that receiving dialysis at home can lead to better quality of life and is less
costly than receiving dialysis in hospital.[50][51] However, many people in the UK prefer to receive
dialysis in hospital: In 2022, only 1 in 6 chose receiving it at home.[50][52][25]
There are various reasons why people do not choose home dialysis. Among these are preferring hospitals
as a way of getting regular social contact, being concerned about necessary changes to their homes and
their family members becoming carers.[50][52] Other reasons include a lack of motivation, doubting
abilities for self-managed treatment, and not having suitable housing or support at home.[25] Hospital
dialysis is also often presented as the norm by healthcare professionals.[25]

Encouraging people to have dialysis at home could reduce the impact of dialysis on people's social and
professional lives.[50][52] Some ways to help are offering peer support from other people on home
dialysis, better education materials, and professionals being more familiar with home dialysis and its
impact. Choosing home dialysis is more likely at kidney centers which have better organisational culture,
leadership and attitude.[25]

United States
Since 1972, insurance companies in the United States have covered the cost of dialysis and transplants for
all citizens.[53] By 2014, more than 460,000 Americans were undergoing treatment, the costs of which
amount to six percent of the entire Medicare budget. Kidney disease is the ninth leading cause of death,
and the U.S. has one of the highest mortality rates for dialysis care in the industrialized world. The rate of
patients getting kidney transplants has been lower than expected. These outcomes have been blamed on a
new for-profit dialysis industry responding to government payment policies.[54][55][56] A 1999 study
concluded that "patients treated in for-profit dialysis facilities have higher mortality rates and are less
likely to be placed on the waiting list for a renal transplant than are patients who are treated in not-for-
profit facilities", possibly because transplantation removes a constant stream of revenue from the
facility.[57] The insurance industry has complained about kickbacks and problematic relationships
between charities and providers.[58]

China
The Government of China provides the funding for dialysis treatment. There is a challenge to reach
everyone who needs dialysis treatment because of the unequal distribution of health care resources and
dialysis centers.[59] There are 395,121 individuals who receive hemodialysis or peritoneal dialysis in
China per year. The percentage of the Chinese population with Chronic Kidney Disease is 10.8%.[60] The
Chinese Government is trying to increase the amount of peritoneal dialysis taking place to meet the needs
of the nation's individuals with Chronic Kidney Disease.[61]

Australia
Dialysis is provided without cost to all patients through Medicare, with 75% of all dialysis being
administered as haemodialysis to patients three times per week in a dialysis facility.[62] The Northern
Territory has the highest incidence rate per population of haemodialysis,[63] with Indigenous Australians
having higher rates of Chronic Kidney Disease and lower rates of functional kidney transplants than the
broader population.[64] The remote Central Australian town of Alice Springs, despite having a population
of approximately 25000, has the largest dialysis unit in the Southern Hemisphere.[65] Many people must
move to Alice Springs from remote Indigenous communities to access health services such as
haemodialysis, which results in housing shortages, overcrowding, and poor living conditions.[66]
History
In 1913, Leonard Rowntree and John Jacob Abel of Johns Hopkins Hospital
developed the first dialysis system which they successfully tested in
animals.[67] A Dutch doctor, Willem Johan Kolff, constructed the first
working dialyzer in 1943 during the Nazi occupation of the Netherlands.[68]
Due to the scarcity of available resources, Kolff had to improvise and build
the initial machine using sausage casings, beverage cans, a washing machine
Arm hooked up to
and various other items that were available at the time. Over the following dialysis tubing.
two years (1944–1945), Kolff used his machine to treat 16 patients with acute
kidney failure, but the results were unsuccessful. Then, in 1945, a 67-year-old
comatose woman regained consciousness following 11 hours of hemodialysis with the dialyzer and lived
for another seven years before dying from an unrelated condition. She was the first-ever patient
successfully treated with dialysis.[68] Gordon Murray of the University of Toronto independently
developed a dialysis machine in 1945. Unlike Kolff's rotating drum, Murray's machine used fixed flat
plates, more like modern designs.[69] Like Kolff, Murray's initial success was in patients with acute renal
failure.[70] Nils Alwall of Lund University in Sweden modified a similar construction to the Kolff dialysis
machine by enclosing it inside a stainless steel canister. This allowed the removal of fluids, by applying a
negative pressure to the outside canister, thus making it the first truly practical device for hemodialysis.
Alwall treated his first patient in acute kidney failure on 3 September 1946.[71]

See also
Thomas Graham (chemist), the founder of dialysis and father of colloid chemistry
Dialysis tubing
List of dialysis providers in the United States
Vitamin and mineral management for dialysis
Nephrology
Hepatorenal syndrome

Notes
a. From Greek διάλυσις, dialysis, 'dissolution'; from διά, dia, 'through', and λύσις, lysis,
'loosening or splitting'

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Further reading
Crowther S, Reynolds L, Tansey T, eds. (2009). History of dialysis in the UK c.1950-1980:
the transcript of a Witness Seminar held by the Wellcome Trust Centre for the History of
Medicine at UCL, London, on 26 February 2008. London: Wellcome Trust Centre for the
History of Medicine at UCL. ISBN 978-0-85484-122-6.

External links
"Machine Cleans Blood While You Wait" ([Link]
BAJ&pg=PA103)—1950 article on early use of dialysis machine at Bellevue Hospital New
York City—an example of how complex and large early dialysis machines were
Home Dialysis Museum ([Link]
upplies/dialysis-museum)—History and pictures of dialysis machines through time
Introduction to Dialysis Machines ([Link]
[Link]/en/app-notes/[Link]/id/4698)—Tutorial describing the main
subfunctions of dialysis systems.
"First Nations man conducts own dialysis treatments to avoid move to the city" ([Link]
[Link]/news/canada/thunder-bay/home-dialysis-1.3873291)—CBC News (November 30,
2016)

Retrieved from "[Link]