11/13/24, 8\:17 PM Guide | Dialysis counselling

Dialysis counselling

Table of contents

Introduction

This article provides a step-by-step approach to counselling patients about dialysis in an OSCE setting, including the
information you will be expected to give and how to structure the consultation.
This guide will cover the two main dialysis modalities (haemodialysis and peritoneal dialysis) with their respective
advantages and disadvantages.

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain the reason for the consultation\:
“ T o d a y I’ d l i k e t o t a l k t o y o u a b o u t t h e o p t i o n s f o r d i a l y s i s , w o u l d t h a t b e o k a y ?”
It is important to establish a good rapport and an open line of communication with the patient early in the consultation\:
h a v e a n y q u e s t i o n s a t a n y p o i n t , o r i f s o m e t h i n g i s n o t c l e a r , p l e a s e f e e l f r e e t o i n t e r r u p t a n d a s k m e .
”
“ I f y o u
Make sure to check the patient’s understanding at regular intervals throughout the consultation and provide opportunities to
ask questions (this is often referred to as ‘chunking and checking’).

Ideas, concerns & expectations

A key component of counselling involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE).
Asking about a patient’s ideas, concerns and expectations can provide insight into how a patient currently perceives their
situation, what they are worried about and what they expect from the consultation. When several treatment options are
available, it is important to explore ICE, as patients may have researched speci
expectations early in the consultation is key, as this may a
It can sometimes be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have
provided some examples for each of the three areas below.

Ideas

What is the patient’s knowledge and understanding of dialysis\:
“ W h a t d o y o u a l r e a d y k n o w a b o u t d i a l y s i s ?”
“ H a v e y o u e v e r h e a r d o f a n y s p e c i
“ D o y o u k n o w a n y t h i n g a b o u t h a e m o d i a l y s i s / p e r i t o n e a l d i a l y s i s ?”

Concerns

Ask if the patient has any concerns about dialysis\:
“ I s t h e r e a n y t h i n g t h a t w o r r i e s y o u a b o u t d i a l y s i s ?”

Expectations

Explore the patients’ expectations for the consultation\:
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“ W h a t w e r e y o u h o p i n g w e w o u l d c o v e r t o d a y r e ga r d i n g d i a l y s i s ?”
“ I s t h e r e a t y p e o f d i a l y s i s y o u w a n t e d t o f o c u s o n ?”

Patient history

Although the purpose of this station is to counsel the patient, it is a good idea to gather a quick, focused history early in the
consultation.
This should include exploring the patient’s condition and reason for requiring dialysis\:
y o u t e l l m e a b i t a b o u t w h y y o u n e e d d i a l y s i s ?”
“ J u s t s o w e a r e o n t h e s a m e p a g e , c o u l d

What is dialysis?

Using patient-friendly language, explain that dialysis is a form of renal replacement therapy (RRT) used in patients with end-
stage renal disease.
1
Usually, healthy kidneys
2
Dialysis is an arti
it is not a cure for kidney disease. 3 4
It allows people to live longer, feel better and continue doing the things they enjoy.
“ N o r m a l l y , t h e k i d n e y s
p a s s e d o u t o f t h e b o d y . W h e n t h e k i d n e y s a r e n’ t w o r k i n g t h e w a s t e p r o d u c t s a n d e x c e s s
t h e b l o o d . T o p r e v e n t d a n g e r o u s b u i l d-u p o f t o x i n s , t h e b l o o d n e e d s t o b e r e g u l a r l y ‘ c l e a n e d’
. D i a l y s i s a c t s a s a n a r t i
c l e a n s i n g y o u r b l o o d d u r i n g t r e a t m e n t , k e e p i n g t h e b o d y i n b a l a n c e .
”

How does dialysis work?

Explain that dialysis works by passing blood on one side of a semi-permeable membrane with dialysate on the other side.
Excess salt,
4,5
“ D i a l y s i s p a s s e s b l o o d o n o n e s i d e o f a
”

What are the types of dialysis?

The two main types of therapy are haemodialysis (HD) and peritoneal dialysis (PD). Haemodialysis is the most common and
well-known type of dialysis. 1
Emphasise that both types of dialysis broadly do the same thing, and neither modality of dialysis
has been proven to be better.
4
Continuous renal replacement therapy (CRRT), or haemo
outpatient setting and will not be discussed further in this article.
“ T h e r e a r e t w o t y p e s o f d i a l y s i s - h a e m o d i a l y s i s a n d p e r i t o n e a l d i a l y s i s . w h i c h t y p e i s b e s t f o r y o u , a s e a c h h a s a d v a n t a g e s a n d d r a w b a c k s .
”
B o t h c l e a r t h e b l o o d o f w a s t e p r o d u c t s . W e w i l l e x p l o r e

Haemodialysis

How does haemodialysis work?

Explain to the patient that during haemodialysis, a machine draws blood from their arm via a
vein and passes it through a dialyser (the “arti
As the blood runs through the dialyser, toxins are
3,5
During dialysis sessions, patients usually sit or lie on a recliner chair or couch. During this time, they can watch TV, use
electronic devices, read or sleep.
7
Haemodialysis can be carried out in a dialysis centre or at home. Patients attending a dialysis centre usually dialyse three
times a week, each lasting three to four hours.
8
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“ H a e m o d i a l y s i s i s p e r f o r m e d u s i n g a n e x t e r n a l m a c h i n e . T h e m a c h i n e h a s a n a r t i
f r o m y o u r b o d y i n t o t h e m a c h i n e . Y o u r b l o o d i s
t h e n p a s s e d b a c k i n t o y o u . T h i s c a n b e d o n e i n a d i a l y s i s c e n t r e o r i n y o u r o w n h o m e . I n a d i a l y s i s c e n t r e , y o u w i l l u s u a l l y h a v e
d i a l y s i s t h r e e d a y s a w e e k w i t h e a c h s e s s i o n l a s t i n g a b o u t t h r e e t o f o u r h o u r s . D u r i n g d i a l y s i s , y o u c a n b e s i t t i n g o r l y i n g d o w n
o n a c h a i r o r c o u c h . Y o u c a n r e a d , w a t c h T V , u s e y o u r p h o n e o r s l e e p .
”

Vascular access

Before haemodialysis treatment can start, there needs to be vascular access (a way of reaching the blood). The preferred
method of access is creating an arteriovenous
vein.
This creates a large blood vessel used as vascular access for the dialysis machine. The surgery is performed at least eight
weeks before starting haemodialysis to allow the
If the patient does not have suitable veins, an arti
a
large vein (normally the jugular).
7,8
“ B e f o r e y o u c a n s t a r t h a e m o d i a l y s i s , t h e r e n e e d s t o b e s o m e w a y f o r y o u t o b e c o n n e c t e d t o t h e m a c h i n e s o t h a t y o u r b l o o d
c a n
a n a r t e r y a n d a v e i n a r e c o n n e c t e d , u s u a l l y i n t h e a r m . T h i s m a k e s a l a r ge b l o o d v e s s e l w h e r e b l o o d c a n b e t r a n s f e r r e d t o a n d
f r o m t h e d i a l y s i s m a c h i n e . T h e
T h e o p e r a t i o n w i l l b e c a r r i e d o u t a t l e a s t e i g h t w e e k s b e f o r e y o u c a n s t a r t h a e m o d i a l y s i s . T h i s a l l o w s e n o u gh t i m e f o r t h e

I f y o u r v e i n s a r e n o t g o o d e n o u g h t o f o r m a
t i m e f o r t h e
i n t o o n e o f y o u r v e i n s .
”

Home dialysis

A patient can be given a simpler dialysis machine to have at home. This dialysis is done more often, usually
week, but with shorter sessions. This can also be done at night while the patient sleeps.
10

Advantages of haemodialysis

Giving the patient enough information is important to make an informed decision. Signposting will help you structure this part
of the consultation.
“ N o w , I’ d l i k e t o t a l k t o y o u a b o u t t h e a d v a n t a ge s a n d d i s a d v a n t a g e s o f h a e m o d i a l y s i s . I s t h i s o k a y w i t h y o u ?”
Dialysis centres
“ T h e r e i s a s o c i a l a s p e c t . Y o u w i l l m e e t o t h e r p e o p l e r e c e i v i n g h a e m o d i a l y s i s , w h i c h m a y gi v e y o u e m o t i o n a l s u p p o r t”
7
Performed by healthcare professionals
“ H a e m o d i a l y s i s i s p e r f o r m e d b y t r a i n e d h e a l t h c a r e p r o f e s s i o n a l s w h o w i l l b e w i t h y o u a t a l l t i m e s d u r i n g t h e t r e a t m e n t”
7
Dialysis free days
“ U n l i k e p e r i t o n e a l d i a l y s i s , y o u d o n o t n e e d t o r e c e i v e d i a l y s i s e v e r y d a y . Y o u w i l l h a v e t h r e e o r f o u r d i a l y s i s-f r e e d a y s”
9
Home haemodialysis advantages
“ I t c a n b e
1 0
L i k e t h r e e t o s e v e n s h o r t t r e a t m e n t s o r f e w e r l o n ge r

Disadvantages of haemodialysis

Restricted
“ D u e t o t h e l o n g e r t i m e s b e t w e e n t r e a t m e n t s , e x c e s s
i n o n l y f o u r h o u r s . M o s t p e o p l e c a n d r i n k o n e t o o n e a n d a h a l f l i t r e s o f
l u n g s a n d t i s s u e s”
4 , 8
Restricted diet
“ A s t h e r e a r e l o n g e r t i m e s b e t w e e n t r e a t m e n t s e s s i o n s , d a n g e r o u s l e v e l s”
4 , 8
s a l t a n d o t h e r m i n e r a l s ( p o t a s s i u m a n d p h o s p h o r u s ) c a n b u i l d u p t o
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Low blood pressure
“ O n e o f t h e m o s t c o m m o n s i d e e
1 1
s i c k o r d i z z y . T h i s i s d u e t o a
Risk of infection
“ H a e m o d i a l y s i s i n c r e a s e s y o u r r i s k o f a l i f e-t h r e a t e n i n g b l o o d i n f e c t i o n c a l l e d s e p s i s . t h r o u g h t h e b l o o d s t r e a m t h r o u g h o u t t h e b o d y , t h i s i s v e r y d a n ge r o u s”
1 1
B a c t e r i a e n t e r t h e b o d y a n d s p r e a d
Muscle cramps
“ S o m e p e o p l e c a n e x p e r i e n c e m u s c l e c r a m p s d u r i n g t r e a t m e n t d u e t o s u d d e n c h a n ge s i n t h e b o d y’ s w a t e r a n d c h e m i c a l
b a l a n c e”
1 1
Feeling itchy
“ B u i l d-u p o f s a l t s a n d m i n e r a l s b e t w e e n d i a l y s i s s e s s i o n s c a n m a k e y o u r s k i n f e e l v e r y i t c h y”
1 1
Requires vascular access (
“ Y o u w i l l h a v e t o h a v e a n o p e r a t i o n t o f o r m a
b e t w e e n d i a l y s i s s e s s i o n s . F i s t u l a s c a n s o m e t i m e s h a v e c o m p l i c a t i o n s l i k e i n f e c t i o n , b l o o d c l o t s a n d s t e n o s i s ( n a r r o w i n g) .
"
1 2
" I f y o u r v e i n s a r e n’ t g o o d e n o u g h f o r a
t h e r e i s i n s u
b e i n s e r t e d i n t o o n e o f y o u r v e i n s .
”
Set schedule & travel
“ F o r t r e a t m e n t i n a d i a l y s i s c e n t r e , y o u’ l l h a v e
3
r e s p o n s i b i l i t i e s a n d
“ S o m e h o s p i t a l s h a v e m o r e t h a n o n e a s s o c i a t e d d i a l y s i s c e n t r e . T r a v e l t o a n d f r o m t h e f a c i l i t y c a n m e a n m o r e t i m e a n d h a s s l e”
7
Home haemodialysis disadvantages
10
“ Y o u w i l l n e e d t o m a k e s p a c e f o r t h e d i a l y s i s m a c h i n e a n d s u p p l i e s”
" T o h a v e h o m e d i a l y s i s , y o u n e e d t o h a v e a t r a i n e d i n d i v i d u a l / p a r t n e r / f a m i l y m e m b e r a t h o m e w i t h y o u”
“ Y o u a n d y o u r p a r t n e r / f r i e n d / f a m i l y m e m b e r w i l l n e e d t o u n d e r g o t r a i n i n g t o p l a c e n e e d l e s f o r a c c e s s , r e c o r d t r e a t m e n t d e t a i l s , m a n a g e y o u r s u p p l i e s a n d o p e r a t e t h e d i a l y s i s m a c h i n e .
”
i n f e c t i o n p r e v e n t i o n ,

Peritoneal dialysis

How does peritoneal dialysis work?

Explain to the patient that peritoneal dialysis uses the peritoneum (abdominal lining) as a natural
inside the body. Dialysis
across the peritoneal membrane into the dialysate.
3, 5
The used dialysis
minutes. This can be performed manually around four times per day (continuous ambulatory peritoneal dialysis) or by a
machine overnight while the patient sleeps (automated peritoneal dialysis).
12, 13
“ P e r i t o n e a l d i a l y s i s u s e s t h e l i n i n g o f y o u r a b d o m e n ( t h e p e r i t o n e u m ) a s a n a t u r a l
b o d y . A t u b e c a l l e d a c a t h e t e r w i l l b e i n s e r t e d i n t o y o u r a b d o m e n . T h r o u gh t h i s c a t h e t e r , t h e d i a l y s i s
b e l l y . W a s t e p r o d u c t s a n d e x c e s s
u s e d
t w e n t y t o t h i r t y m i n u t e s a n d n e e d s t o b e r e p e a t e d m u l t i p l e t i m e s a d a y , e v e r y d a y . T h i s c a n b e d o n e w h i l e y o u a r e a w a k e
( u s u a l l y f o u r t i m e s p e r d a y ) o r a u t o m a t i c a l l y b y a m a c h i n e w h i l e y o u s l e e p .
”

Peritoneal dialysis catheter

Inform the patient that before starting peritoneal dialysis, they must have a small procedure to place a tunnelled peritoneal
dialysis catheter. Under local or general anaesthetic, an incision will be made in the skin below the umbilicus, where the
catheter is inserted into the abdomen. It then runs under the skin and exits in the left or right
14, 15
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“ B e f o r e y o u c a n s t a r t p e r i t o n e a l d i a l y s i s y o u w i l l n e e d a s m a l l p r o c e d u r e t o p l a c e a t u b e k n o w n a s a c a t h e t e r . A c u t w i l l b e
m a d e j u s t b e l o w y o u r b e l l y b u t t o n a n d a c a t h e t e r w i l l b e i n s e r t e d a n d t h e n r u n u n d e r t h e s k i n e x i t i n g i n t h e l e f t o r r i g h t
T h i s c a t h e t e r w i l l s t a y i n y o u r a b d o m e n p e r m a n e n t l y . T h i s i s s o t h e d i a l y s i s
”

Types of peritoneal dialysis

“ C h a n g i n g t h e d i a l y s i s
m a c h i n e o v e r n i g h t w h i l e a s l e e p . T h e s e a r e c a l l e d c o n t i n u o u s a m b u l a t o r y a n d a u t o m a t e d p e r i t o n e a l d i a l y s i s , r e s p e c t i v e l y”
3
Continuous ambulatory peritoneal dialysis (CAPD)
In CAPD, patients constantly have dialysis
themselves. Each
3,12,15
“ Y o u w i l l h a v e d i a l y s i s s o l u t i o n i n y o u r a b d o m e n a t a l l t i m e s . A m b u l a t o r y m e a n s t h a t y o u w o n’ t b e a t t a c h e d t o a m a c h i n e a n d
w i l l b e a b l e t o g o a b o u t y o u r d a y . Y o u w i l l p e r f o r m t h e d i a l y s a t e
e x c h a n g e s p e r d a y , e a c h t a k i n g a r o u n d h a l f a n h o u r .
”
Automated peritoneal dialysis (APD)
In APD, the dialysate exchange is ‘automated’ and performed by a machine overnight while the patient is asleep. The patient
connects to the machine each night. They need to be attached for around ten hours.
3,12,15
“ T h e p e r i t o n e a l d i a l y s i s w i l l o c c u r o v e r n i gh t . B e f o r e y o u g o t o b e d y o u a t t a c h y o u r s e l f t o a m a c h i n e t h a t c o n t i n u o u s l y r e p l a c e s
t h e d i a l y s i s
”

Advantages of peritoneal dialysis

Less restriction on diet and
“ A s y o u h a v e m o r e c o n t i n u o u s d i a l y s i s t r e a t m e n t s , t h e r e a r e f e w e r r e s t r i c t i o n s o n d i e t a n d
9
.
Responsibility to manage own care
“ Y o u p e r f o r m p e r i t o n e a l d i a l y s i s y o u r s e l f”
3
.
Flexibility of treatment
“ T r e a t m e n t i s
3 , 1 5
.
s c h o o l o r t r a v e l p l a n s b e c a u s e y o u a r e i n c h a r ge o f y o u r o w n
No needles
“ D i a l y s a t e i s p a s s e d i n a n d o u t v i a t h e c a t h e t e r . T h e r e a r e n o n e e d l e s u s e d d u r i n g t h e p r o c e s s .
”
Travel and holidays
“ W i t h p e r i t o n e a l d i a l y s i s , c a n b e e a s i e r t o o r ga n i s e t r a v e l . Y o u j u s t n e e d t o ge t d i a l y s i s
3 , 1 5
.
CAPD advantages
“ Y o u d o n o t n e e d a m a c h i n e t o p e r f o r m d i a l y s a t e e x c h a n ge s .
”
“ W i t h C A P D , e x c h a n g e s c a n b e v a r i e d t o
”
“ E x c h a n g e s c a n b e p e r f o r m e d a n y w h e r e y o u c a n a c c e s s h a n d w a s h i n g f a c i l i t i e s a n d a c l e a n a b l e s u r f a c e l i k e a p l a s t i c t r a y . T h i s
p o r t a b l e e q u i p m e n t m e a n s y o u c a n t r a v e l a w a y f r o m h o m e .
”
APD advantages
“ W i t h A P D , n o d i a l y s i s e x c h a n g e o c c u r s d u r i n g t h e d a y .
”

Disadvantages of peritoneal dialysis

Every day is a dialysis day
“ P e r i t o n e a l d i a l y s i s n e e d s t o b e c a r r i e d o u t e v e r y d a y , t h e r e a r e n o d i a l y s i s-f r e e d a y s”
9
.
Permanent catheter
“ T h e c a t h e t e r w i l l b e h i d d e n u n d e r y o u r c l o t h e s , a b d o m e n”
9
.
b u t s o m e p e o p l e c a n
“ S o m e t i m e s t h e r e c a n b e p r o b l e m s w i t h t h e c a t h e t e r s u c h a s i n f e c t i o n , b l o c k a g e , k i n k i n g, l e a k s a n d d i s p l a c e m e n t”
1 2
.
Risk of an abdominal infection (peritonitis)
“ P e r i t o n i t i s i s a n i n f e c t i o n o f t h e m e m b r a n e l i n i n g y o u r a b d o m e n c a l l e d t h e p e r i t o n e u m . p o t e n t i a l l y l i f e-t h r e a t e n i n g”
9 ,1 1
.
P e r i t o n i t i s i s v e r y d a n ge r o u s a n d
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Ownership over health and meticulous cleanliness
“ T o a v o i d d a n g e r o u s i n f e c t i o n , y o u m u s t b e v e r y c l e a n a n d a l w a y s u s e b e s t p r a c t i c e . A n y b a c t e r i a l e f t o n t h e d i a l y s i s
e q u i p m e n t c a n s p r e a d i n t o t h e a b d o m e n”
1 1 ,1 5
.
Thickening and scarring of the peritoneum
“ O v e r s e v e r a l y e a r s , t h e n a t u r a l
1 1 ,1 2
.
i t
Weight gain and e
“ T h e d i a l y s i s
t h i s s u g a r , s i g n i
i n b l o o d s u g a r s a n d m a k e i t h a r d e r t o c o n t r o l y o u r b l o o d s u g a r l e v e l s .
”
1 1
Risk of hernia
“ H o l d i n g l o t s o f
s t r a i n i n g o r b e n d i n g o v e r . U s u a l l y , t h i s w i l l n e e d t o b e r e p a i r e d w i t h s u r ge r y .
”
1 1
Preventing constipation
Patients should know that constipation can press on the catheter or cause it to move out. This can make it di

“ I t' s i m p o r t a n t t o k e e p t h e b o w e l s r e g u l a r l y w o r k i n g d u r i n g p e r i t o n e a l d i a l y s i s . a n d o u t o f y o u r a b d o m e n”
1 6
.
C o n s t i p a t i o n c a n i n t e r f e r e w i t h h o w
Continuous ambulatory peritoneal dialysis (CAPD) disadvantages
“ H a v i n g t o p e r f o r m
”
“ A s i t i s c o n t i n u o u s , y o u w i l l a l w a y s h a v e
”
Automated peritoneal dialysis APD disadvantages
“ Y o u w i l l n e e d t o m a k e s p a c e f o r a m a c h i n e a n d s u p p l i e s i n y o u r h o m e .
”
“ B e i n g c o n n e c t e d t o t h e m a c h i n e f o r e i gh t t o t e n h o u r s a n i g h t c a n l i m i t y o u r m o v e m e n t .
”

Closing the consultation

Close the consultation by summarising what you have discussed. This allows you to emphasise the key points of the
consultation.
Finally, thank the patient for their time and o
(e.g. haemodialysis lea, peritoneal dialysis lea)
Dispose of PPE appropriately and wash your hands.

Summary table

Dialysis
type
What
How
Haemodialysis Peritoneal dialysis
Diverting blood into an external machine, the
blood is
body.
Dialysis centre (or at home). Using a dialysis
machine 3 times/week, each session lasts 4
hours.
Passing dialysis
cavity via a permanent catheter. The dialysate
draws out waste products from the blood
passing through vessels lining the inside of
the abdomen.
Performed at home.
CAPD\: 20-30 minute exchange, 4 times per
day
APD\: Dialysis machine attached to catheter
around 10 hours each night
https\://app.geekymedics.com/osce-guides/counselling/dialysis-counselling/ 6/811/13/24, 8\:17 PM Guide | Dialysis counselling
Pros
3-4 dialysis-free days a week
Dialysis centres are widely available
Socially meet other people undergoing
dialysis
Performed by healthcare professionals
Less restriction on
Performed by the patient
Flexibility
No regular visits to a centre
No needles
Easier to travel and go on holidays
Cons
Restricted
Restricted diet
Low blood pressure
Sepsis
Muscle cramps
Feeling itchy
Surgery to create an AV
before dialysis can start.
Complications associated with an AV

Set schedule and planning life around
dialysis sessions
Travel to the dialysis centre
Must be carried out every day
Abdominal catheter
Risk of peritonitis (infection of the
membrane lining the abdomen)
Responsibility for cleanliness and own
health
Scarring of the peritoneum
Weight gain
Rise in blood sugars in diabetic patients
Hernias

Reviewer

Dr Mahzuz Karim
Consultant Nephrologist
Norfolk and Norwich University Hospital

References

1. GOV.UK. Dialysis guidance. 2022. Available from\: [LINK]
2. Kidney Patient Guide. Dialysis treatment. 2021. Available from\: [LINK]
3. Dialysis overview. 2021. Available from\: [LINK]
4. Haemodialysis. 2018. Available from\: [LINK]
5. Wilkinson I, Raine T, Wiles K, Goodhart A, Hall C, O’Neill H. Oxford handbook of clinical medicine. 10th ed. Oxford University
Press; 2017.
6. Kellum,JA, Bellomo R, Ronco C. Continuous Renal Replacement Therapy. Oxford University Press, 2016.
7. NHS Cambridge University Hospitals. A patients guide to haemodialysis. 2019. Available from\: [LINK]
8. NHS.uk Dialysis How it’s performed. 2021. Available from\: [LINK]
9. NHS.uk. Dialysis pros and cons. 2021. Available from\: [LINK]
10. Home dialysis the advantages. 2019. Available from\: [LINK]
11. NHS.uk. Dialysis side eLINK]
12. Tidy, C. Renal replacement therapy and transplantation. 2022. Available from\: [LINK]
13. Kidney Care UK. Peritoneal dialysis. Available from\: [LINK]
14. North Bristol NHS Trust. Peritoneal Dialysis catheter insertion. 2020. Available from\: [LINK]
15. NHS Cambridge university hospitals. What I need to know about choosing peritoneal dialysis. 2021. Available from\: [LINK]
16. NHS Hull University Teaching Hospitals. Constipation in Kidney disease. 2020. Available from\: [LINK]
https\://app.geekymedics.com/osce-guides/counselling/dialysis-counselling/ 7/811/13/24, 8\:17 PM Guide | Dialysis counselling
Source\: geekymedics.com
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