Treatment Methods for Kidney Failure in Children


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Treatment Methods for Kidney Failure in Children

  1. 1. Treatment Methods for Kidney Failure in Children K idneys play an important part in Treatment Methods for a child’s growth and health. They Problems Specific to Children Everyone who has kidney failure, adults and children alike, will experience med- the blood Kidney Failure in Children remove wastes and extra water from ical complications, which may include extreme fatigue, inability to concen- trate, weak bones, nerve damage, regulate blood pressure depression, and sleep problems. Addi- potassium K idneys play an important part in They Problems Specific to Children a child’s growth and health.tional problems for children can include balance chemicals like sodium and Everyone who has kidney failure, adults remove wastes and extra water from and children alike, will experience med- ical complications, which may include make a hormone that signals bone the blood extreme fatigue, inability to concen- marrow to make red blood cells trate, weak bones, nerve damage, regulate blood pressure depression, and sleep problems. Addi- make a hormone to help bones like sodium and balance chemicals grow tional problems for children can include and keep them strong potassium Kidney failure can make directly to more bone lead a hormone that signals marrow to make red blood cells health problems, like swelling of the body, bone deformities, a hormone to help bones grow make and growth fail- Kidneys and keep them strong ure. A successful kidney transplant can give a child withKidney failure can lead directly to more chronic kidney failure health problems, like swelling of the the best chance to grow normally and Ureters body, bone deformities, and growth fail- Kidneys lead a full, activeure. A successful can help life. Dialysis kidney transplant can a child to survive an aacute with chronic kidney failure give child episode of kidney failure orthe best chance to grow normally and to stay healthy until a Ureters donated kidney becomes active life. lead a full, available. Dialysis can help a child to survive an acute episode of Families caring for a child withto stay healthy until a kidney failure or kidney disease often need help—not becomes available. donated kidney just from Bladder doctors and nurses, but caring for a child with kidney Families from a whole team of pediatric specialists, including just from disease often need help—not Bladder doctors and nurses, but from a whole dietitians, social workers, and family team of pediatric specialists, including counselors. Learning about treatments family dietitians, social workers, and for kidney disease and getting to know treatments counselors. Learning about The kidneys remove wastes and extra water from the the entire team can kidney disease and getting to know to form urine. Urine flows fromextra water fromto for make life easier for blood The kidneys remove wastes and the kidneys the your child and yourentire team can make life easier for the entire family. the bladder blood to form urine. Urine flows from the kidneys to through the ureters. your child and your entire family. the bladder through the ureters. National Institute of Diabetes and Digestive and Kidney Diseases U.S. Department of Health National Institute of Diabetes and Digestive OF HEALTH Diseases NATIONAL INSTITUTES and Kidney U.S. DepartmentServices and Human of Health NATIONAL INSTITUTES OF HEALTH and Human Services Phone: 800.633.6628 •
  2. 2. effects on their growth and development. In adults, most transplanted kidneys come Children may fall behind on the growth chart from people who have just died. However, and in school. about half of the kidney transplants in children come from a living donor, usually The isolation people feel because of kidney a parent or other close family member. failure is especially a problem in children and adolescents because of the importance of mak- Deceased Donor Kidneys ing friends and fitting in at this age. Finding To receive a deceased donor kidney, your child the best treatment for a child takes on special will be placed on a waiting list. Every person significance to ensure that the child with kid- who needs an organ from a deceased donor is ney failure can become an active, productive, registered with the United Network for Organ well-adjusted adult. Sharing (UNOS), which maintains a central- ized computer network linking all regional Treatment Choices for Kidney Failure organ gathering organizations and transplant in Children centers. (See the Resources section at the end Children usually have a range of treatment of this fact sheet.) options for kidney failure. In most cases, the How long your child will have to wait for a goal is to have a successful transplant that transplant depends on many things but is allows your child to lead the most normal life determined primarily by how good the match possible. But viable kidneys are not always is between your child and a donor. When a readily available, and not all children can have kidney becomes available, the hospital that has a transplant. Many children begin with dialy- obtained the kidney reports to UNOS, where sis to stay healthy until a suitable kidney the central computer generates a list of com- becomes available. Sometimes, a transplant patible recipients. Candidates’ ages and length itself may stop working, and the child may of time they have waited are factors in the need to return to dialysis. Knowing about point system. Children 18 and under get extra transplantation and dialysis will prepare you and your child for any circumstance. Diseased kidneys Transplantation Transplantation means that a healthy kidney from a donor is placed inside a child’s body to take over the job of filtering wastes and extra fluid from the blood. The donor may be a Vein stranger who has just died or a living family member or friend. Artery Transplanted Once kidneys fail because of chronic kidney kidney disease, function cannot be restored, so trans- plantation is the closest thing to a cure we have. A child with a transplant will still need to take medicines every day, follow a restricted diet, and get regular checkups to make sure Bladder Transplanted ureter the new kidney is accepted and functioning in the body. Kidney transplantation 2
  3. 3. points compared with adults because they are Preemptive Transplantation likely to receive the greatest benefit from a Preemptive transplantation means that the donated kidney. child receives a donated kidney before dialysis is needed. Some studies indicate that preemp- tive transplantation reduces the chances of While your child is on the waiting list, notify the rejecting the new kidney and improves the transplant center of any changes in health status, chances that it will function for a long time. address, or phone number. The center will need Other studies show little or no survival advan- to find you immediately when a kidney becomes tage in preemptive transplants, although some available. families may feel that avoiding dialysis is an advantage in itself. Living Donor Kidneys Keeping a Healthy Kidney About half of the kidneys transplanted into Health professionals use the term “noncom- children are donated by family members— pliance” or “nonadherence” to describe a usually a parent—or a family friend. Potential patient’s failure or refusal to take prescribed donors need to be tested for matching factors medicines or follow a doctor’s directions. and to make sure that donating a kidney will Teenagers with transplanted organs are often not endanger their health. Most people can noncompliant because the immunosuppressive donate a kidney with little risk. drugs they must take change their appearance in unflattering ways. A child psychologist may A kidney from a living donor often has advan- be able to suggest techniques that reinforce tages over a kidney from a person who has just desired behaviors. But communicating clearly died. about the reasons for treatment and the I A kidney from a parent is guaranteed to importance of following the regimen is an match on at least three of six proteins; important part of helping all patients, includ- mismatched proteins may cause rejection. ing children. Children who understand that their decisions can affect their health are more I Living donation allows for greater prepara- likely to take responsibility for their actions. tion and for the operation to be scheduled. For more information about transplantation I A kidney from a living donor may be in bet- procedures, see the National Institute of ter condition because it does not have to be Diabetes and Digestive and Kidney Diseases transported from one site to another. (NIDDK) booklet Treatment Methods for Kidney Failure: Transplantation. 3
  4. 4. Dialysis I Continuous ambulatory peritoneal dialysis The kidneys remove waste products and extra (CAPD). CAPD requires no machine and water from the blood. If the kidneys fail can be done in any clean, well-lit place. before transplantation is possible, your child With CAPD, your child’s blood is always may need some form of dialysis to do this job. being cleaned. The dialysis solution passes Each type of dialysis will affect your family’s from a plastic bag through the catheter and lifestyle. Your doctor will help you choose the into the abdomen, where it stays for several one that is best for your child. Each situation hours with the catheter sealed. After the is different. dwell time, the child drains the dialysis solution into a drain bag for disposal. Peritoneal Dialysis Then the same catheter is used to refill the Peritoneal dialysis uses the lining of your abdomen with fresh solution so the clean- child’s abdomen, called the peritoneal mem- ing process can begin again. With CAPD, brane, to filter blood. A mixture of minerals the dialysis solution stays in the abdomen and sugar dissolved in water, called dialysis for 4 to 6 hours or more. Most people solution, is inserted into your child’s abdomen change the dialysis solution at least four through a soft tube. The sugar, called dex- times a day and sleep with solution in their trose, draws wastes, chemicals, and extra abdomen at night. With CAPD, it is not water from the tiny blood vessels in the peri- necessary to perform an exchange during toneal membrane into the dialysis solution. the night. After some time, the used solution—now I Continuous cycling peritoneal dialysis loaded with the wastes and extra fluid that the (CCPD). CCPD uses a machine called kidneys would have filtered out—is drained a cycler to fill and empty your child’s from your child’s abdomen through the tube. abdomen many times at night during sleep. The period that dialysis solution is in the In the morning, the child begins one abdomen is called the dwell time. The abdomen is filled again with fresh dialysis solution, and the cycle repeats. The process of Dialysate emptying and refilling the abdomen is called an exchange and takes about 30 to 40 minutes. Before the first treatment, a surgeon will place a small, soft tube called a catheter into your child’s abdomen. The catheter tends to work better if the insertion site has time—usually from 10 days to 3 weeks—to heal. The catheter stays there to help transport dialysis solution to and from the abdomen and is removed only after a successful transplant Catheter is in place. Peritoneum Peritoneal dialysis can be done with or without Abdominal a cycling machine. cavity Peritoneal dialysis 4
  5. 5. exchange with a dwell time that lasts the entire day. An additional exchange without Hemodialyzer the cycler may be added in the middle of (where filtering takes place) the afternoon to increase the amount of waste removed and to reduce the amount of fluid left behind. Both types of peritoneal dialysis can be per- formed in the home without help from a nurse or doctor. If your child is very young, you will need to help with the exchanges or set up the cycler. Older children can do it themselves. You and your child will receive detailed instructions and extensive training so you feel confident when you perform the exchanges. The most common problem with peritoneal dialysis is peritonitis, a serious abdominal Hemodialysis Unfiltered blood flows Filtered blood flows back infection that can occur if the opening where machine to dialyzer to body the catheter enters the body becomes infected Hemodialysis or if contamination occurs as the catheter is connected or disconnected from the bags. Peritonitis requires antibiotic treatment pre- Hemodialysis uses a special filter called a dia- scribed by your child’s nephrologist. lyzer. During treatment, blood travels from the child’s body through tubes into the dialyz- To avoid peritonitis, you must be careful to er, which filters out wastes and extra water. Then the cleaned blood flows through another follow the correct procedures exactly and learn set of tubes back into the child’s body. The to recognize the early signs—fever, unusual dialyzer is connected to a machine that moni- color or cloudiness of the used fluid, and tors blood flow and disposes of the wastes. redness or pain around the catheter. Report Hemodialysis usually takes place in a clinic these signs to your child’s doctor immediately three times a week, but it may be required so treatment for infection can begin promptly. more often in smaller children. Each treat- ment lasts from 3 to 4 hours. Some clinics For more information about peritoneal dialy- offer home hemodialysis, which allows more sis, see the NIDDK booklet Treatment Methods flexibility in scheduling but requires the care- for Kidney Failure: Peritoneal Dialysis. giver to take weeks of training. During treat- ment, the child can do homework, read, write, Hemodialysis sleep, talk, or watch TV . In hemodialysis, your child’s blood is sent If you choose hemodialysis, the doctor will through a filter to remove harmful wastes, need to create an access to the bloodstream extra salt, and extra water. Hemodialysis (vascular access) several months before the helps control blood pressure and keep the first treatment. The child may be able to com- proper balance of potassium, sodium, calcium, plete the procedure for the vascular access in and bicarbonate. 5
  6. 6. one day or may need to stay overnight in the are working, the doctor may decide to moni- hospital. tor your child or advise you to see a specialist. (Your health insurance plan may require a For more information, see the NIDDK fact written referral from the pediatrician in order sheet Vascular Access for Hemodialysis. for you to make an appointment with a spe- When a child starts hemodialysis, problems cialist.) As your child’s regular doctor, the can be caused by rapid changes in the body’s pediatrician should talk with any specialists water and chemical balance during treatment. who become involved. A referral for consulta- Muscle cramps and a sudden drop in blood tion should optimally occur soon after chronic pressure are two common side effects. Low kidney disease is diagnosed, even if dialysis blood pressure, called hypotension, can make and transplantation are still a long way off. a child feel weak, dizzy, or nauseated. Nephrologist Most children need a few months to adjust to A nephrologist is a doctor who treats kidney hemodialysis. Side effects can often be treated diseases and kidney failure. If possible, your quickly and easily, so you should always report child should see a pediatric nephrologist them to your doctor and dialysis staff. You because they are specifically trained to take can avoid many side effects by making sure care of kidney problems in children. In many your child gets a proper diet, limits liquid areas of the country, pediatric nephrologists intake, and takes all medicines as directed. are in short supply, so you and your child may See page 7 for more information on how the need to travel. If traveling is not possible, right food choices can help. some nephrologists who treat adults can also For more information about hemodialysis, see treat children in consultation with a pediatric the NIDDK booklet Treatment Methods for nephrologist. Kidney Failure: Hemodialysis. The nephrologist may prescribe treatments to slow disease progression and will determine Role of the Health Care Team when referral to a transplant center or to a Because the treatments for kidney failure dialysis clinic is appropriate. involve complicated procedures with a number of steps, many skilled professionals must work Dialysis Nurse together to ensure that your child gets the best If your child needs dialysis, a nurse with spe- possible care. As a parent or guardian, you are cial training will make sure all procedures are the most important member of your child’s followed carefully. If you and your child team. You may need to speak for your child choose peritoneal dialysis, the dialysis nurse or ask questions when instructions are not will train you so you feel comfortable doing clear. Knowing the roles of the different team the exchanges at home. For hemodialysis in a members can help you ask the right questions clinic, the dialysis nurse will make sure that all and contribute to your child’s care. needles are placed correctly and watch for any problems. The dialysis nurse can talk to you Pediatrician about the advantages and disadvantages of the A pediatrician is a doctor who treats children. different types of dialysis and explain the labo- Your child’s pediatrician is likely to be the first ratory reports that indicate how well the treat- to recognize a kidney problem—either during ments are working. a routine physical exam or while treating an ailment. Depending on how well the kidneys 6
  7. 7. Transplant Coordinator Dietitian A coordinator at the transplantation center When the kidneys stop working, wastes and will be your main contact. He or she will excess fluid build up in the body and create schedule any required examinations and pro- chemical and hormonal imbalances. In chil- cedures and make sure your child’s medical dren, however, these problems are especially information is complete and properly placed troublesome because they can interfere with on the UNOS national waiting list. The trans- physical growth and mental development. plant coordinator will make sure that every Avoiding certain foods can help minimize member of the child’s health care team has all the buildup of wastes and prevent chemical the necessary information and paperwork. imbalance, but it can also lead to nutritional deficiencies. The buildup of wastes often Social Worker makes children lose their appetite, causing Every dialysis clinic and transplant center has further nutritional problems. These compli- a social worker who can help you locate finan- cations are the reason your clinic’s dietitian cial assistance and social services like trans- is so important. portation or family counseling and help with Proper nutrition is extremely important for applications for Medicare. The social worker children with chronic kidney disease. Every can tell you about support groups in your dialysis clinic has a dietitian to help patients community and ways to reduce the stress that understand how the food they eat affects their caring for a child with a chronic illness can health. The dietitian can help you develop cause. meal plans that will fit your child’s restricted diet and will talk with you about laboratory Psychologist, Psychiatrist, or Counselor reports that may show nutritional deficiencies Kidney disease can disrupt a child’s life and caused by your child’s kidney disease. They create emotional turmoil. A psychologist or may recommend special dietary supplements counselor can help your child find ways to or formulas so that your child receives the best express emotions constructively. Adults and nutrition possible. siblings may also find that counseling helps them with the conflicts and stresses they face. You can also ask your dietitian for recipes and For example, medical bills can strain family titles of cookbooks for patients with kidney finances. A parent or guardian may need to disease. Following the restrictions of a kidney give up work to care for the child full-time. disease diet might be hard at first, but with a Siblings may feel resentment over the huge little creativity, you can make tasty and satisfy- amount of attention given to their sibling and ing meals. Reading Eat Right to Feel Right on guilt over thinking bad thoughts about the sick Hemodialysis, a booklet from the NIDDK, can child. Couples sometimes report increased ten- help you get started. sion in their marriage when a child is sick. A counselor can help families deal with conflicts Vaccinations and Immunosuppression that may arise, and social workers or financial The wastes and toxins that build up in the counselors can help families meet the financial bloodstream of a child with kidney disease obligations that chronic illness creates. can weaken the immune system and make the child vulnerable to infections and the kinds of diseases that vaccines are designed to prevent. Children with kidney failure should receive 7
  8. 8. the standard vaccinations recommended for all tired, limit physical growth, and interfere with children, plus additional vaccinations for their ability to concentrate in school. pneumonia and influenza. Children who take immunosuppressive med- Anemia ication to treat an autoimmune disease or to Diseased kidneys do not make enough of a prevent rejection of a transplanted kidney, hormone called erythropoietin, or EPO, which however, should not receive vaccines contain- stimulates the bone marrow to produce the ing live viruses, that is, the oral polio vaccine, red blood cells needed to carry oxygen to vital the measles, mumps, and rubella (MMR) vac- organs. Anemia is a shortage of red blood cine, or the varicella (chicken pox) vaccine. cells, and it is common in children with kidney Children who are likely to need a transplant disease. A child with anemia may tire easily may benefit from early immunization with and look pale. Anemia may also contribute to these vaccines before immunosuppressive heart problems. A genetically engineered form drugs are needed. of EPO injected under the skin one or more times a week can treat this form of anemia. The body’s immune system protects against foreign substances like bacteria and viruses For more information, see the NIDDK fact that can cause disease. But the immune system sheet Anemia in Kidney Disease and Dialysis. also attacks transplanted organs, and the medi- cines that recipients must take to prevent Bone Problems and Growth Failure rejection leave them vulnerable to infections. The kidneys help keep bones healthy by Children need relatively higher doses of balancing phosphorus and calcium levels in immunosuppressive drugs than adults because the blood. When the kidneys stop working their immune systems are more active. But normally, phosphorus levels in the blood can these high doses can slow down growth and become high and interfere with bone forma- development. Over a long period of time, tion and normal growth. immunosuppression may lead to malignant Your child’s doctor may recommend dietary growths. Immunosuppressive drugs can also changes and food supplements to treat growth have side effects such as weight gain, unusual failure. Dietary changes may include limiting hair growth, and acne. Children, especially foods that contain large amounts of phospho- teenagers, cite these side effects as the reason rus, such as milk, cheese, cola, dried beans, they do not take their pills, a problem that peas, and nuts. Since avoiding all of these contributes to the high rate of organ rejection foods is impossible, caregivers will need to in children. work with a dietitian to find a healthy way to limit the phosphorus in the child’s diet while Medical Complications of maintaining a desirable intake of the calories, Kidney Failure protein, and other nutrients necessary to main- tain growth and general health. In addition to The kidneys not only clean waste and extra dietary restrictions, most children will need to fluid from the blood, they also help make red take specific medications called phosphate blood cells and balance nutrients needed for binders to lower their blood phosphorus levels. strong bones and growth. In addition, the kid- neys may play a role in the metabolism of For more information, see the NIDDK fact growth hormone (somatotropin). Chronic sheet Growth Failure in Children With Kidney kidney disease can make children feel more Disease. 8
  9. 9. Financial Help for Treatment Resources Resources of Kidney Failure Websites Websites No matter what treatment method your family Several agencies andand organizations maintain Several agencies organizations maintain chooses, medical expenses will be high. Fortu- informative websites for for people with kidney informative websites people with kidney nately, the Federal Government and many disease. The following sites are are designed disease. The following sites designed other organizations offer programs to help specifically for for children and their parents or specifically children and their parents or with the cost of treatments. guardians: guardians: Medicare MEDLINEplus: Kidney Diseases (General) MEDLINEplus: Kidney Diseases (General) In 1972, Congress passed legislation making people with permanent kidney failure, no kidneydiseasesgeneral.html kidneydiseasesgeneral.html matter what their age, eligible for Medicare, a The National Library of Medicine maintains The National Library of Medicine maintains program that helps people over 65 and people MEDLINEplus, a resource providing health MEDLINEplus, a resource providing health with disabilities pay for medical care. information for for consumers. The page kid- information consumers. The page on on kid- neyney diseases contains linksnews articles andand diseases contains links to to news articles factfact sheets about kidney diseases under many sheets about kidney diseases under many Role of the Social Worker headings, including “Children.” headings, including “Children.” Your child’s dialysis or transplant center has a social worker who can help you apply for The Nemours Foundation’s The Nemours Foundation’s Medicare and locate other sources of financial assistance. For more information about chronic_kidney_disease.html chronic_kidney_disease.html Medicare and other organizations that can help, see the NIDDK fact sheet Financial Help dialysis.html dialysis.html for Treatment of Kidney Failure. The Nemours Foundation supports children’s The Nemours Foundation supports children’s hospitals in Delaware andand Florida. The Kids- hospitals in Delaware Florida. The Kids- Hope Through Research Health website includes articles on many Health website includes articles on many Through its Division of Kidney, Urologic, and health topics written for for parents, teenagers, health topics written parents, teenagers, Hematologic Diseases, the NIDDK supports andand young children. The pages listed above young children. The pages listed above several programs and studies devoted to contain “When Your Child Has a Chronic contain “When Your Child Has a Chronic improving treatment for patients with progres- Kidney Disease” andand “What’s the Deal With Kidney Disease” “What’s the Deal With sive kidney disease and kidney failure. The Dialysis?”—an article written for for children. Dialysis?”—an article written children. NIDDK maintains the Pediatric Nephrology YouYou can click “Related Articles” andand find can click on on “Related Articles” find Program, which supports research into the several more KidsHealth pages devoted to to several more KidsHealth pages devoted causes, treatment, and prevention of kidney kidney diseases andand their treatments. kidney diseases their treatments. diseases in children, including congenital National Kidney Foundation: Children With National Kidney Foundation: Children With malformations of the urinary tract, polycystic Chronic Kidney Diseases: Tips for for Parents Chronic Kidney Diseases: Tips Parents disease, primary glomerular disease, and post- infection glomerulonephritis. The National Kidney Foundation has has devel- The National Kidney Foundation devel- oped many programs to help support andand oped many programs to help support educate patients and their families. This page e contains “Children With Chronic Kidney Dis- ease: Tips for Parents,” which is also available in brochure form (see Additional Reading). 9
  10. 10. Kidney Directions: KD Kids LLife Options Rehabilitation Program c/o Medical Education Institute Inc. index.htm 414 D’Onofrio Drive The Kidney Directions website was developed Suite 200 by a manufacturer of dialysis equipment. The Madison, WI 53719 KD Kids page offers information for parents Phone: 1–800–468–7777 or 608–232–2333 and children about kidney disease and its Email: complications. Internet: Nephkids Cyber-Support Group for Parents of Children With Kidney Disease National Kidney Foundation United Network for Organ Sharing 30 East 33rd Street P Box 2484 .O. Nephkids is a listserv, an interactive email New York, NY 10016 Richmond, VA 23218 group for parents of children with various Phone: 1–800–622–9010 or 212–889–2210 Phone: 1–888–894–6361 chronic kidney diseases. Email: Internet: Internet: For More Information O U A American Association of Kidney Patients American Society of Pediatric Nephrology 3505 East Frontage Road Northwestern University Suite 315 Feinberg School of Medicine Tampa, FL 33607 Pediatrics W140 Phone: 1–800–749–2257 or 813–636–8100 303 East Chicago Avenue Email: Chicago, IL 60611–3008 Internet: Phone: 312–503–4000 Email: American Kidney Fund Internet: 6110 Executive Boulevard Suite 1010 Rockville, MD 20852 Phone: 1–800–638–8299 or 301–881–3052 E Email: Internet: 10
  11. 11. National Kidney and Urologic Diseases Information Clearinghouse 3 Information Way Bethesda, MD 20892–3580 Phone: 1–800–891–5390 Fax: 703–738–4929 Email: Internet: The National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health under the U.S. Department of Health and Human Services. Established in 1987, the Clearinghouse provides information about dis- eases of the kidneys and urologic system to peo- ple with kidney and urologic disorders and to their families, health care professionals, and the public. The NKUDIC answers inquiries, devel- ops and distributes publications, and works closely with professional and patient organi- zations and Government agencies to coordinate resources about kidney and urologic diseases. Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts. The NKUDIC would like to thank Barbara Fivush, M.D., and Kathy Jabs, M.D., of the American Society of Pediatric Nephrology (ASPN), for coordinating the review of this fact sheet by the ASPN’s Clinical Affairs Committee: Tej Mattoo, M.D., William Primack, M.D., Joseph Flynn, M.D., Ira Davis, M.D., Ann Guillott, M.D., Steve Alexander, M.D., Deborah Kees-Folts, M.D., Alicia Neu, M.D., Steve Wassner, M.D., John Brandt, M.D., Manju Chandra, M.D. Frederick Kaskel, M.D., Ph.D., President, ASPN, and Sharon Andreoli, M.D., Secretary–Treasurer, ASPN, also provided comments and coordination. This publication is not copyrighted. The Clearinghouse encourages users of this fact sheet to duplicate and distribute as many copies as desired. This fact sheet is also available at U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health NIH Publication No. 06–5082 April 2006