6–8 Week Preparation Guide

Certifying Body: Nephrology Nursing Certification Commission (NNCC)

Exam: Certified Dialysis Nurse (CDN)

Format: 150 multiple-choice questions

Time: 3 hours

Prerequisites: Active RN license + at least 2,000 hours (approximately 1 year) of nephrology/dialysis nursing experience in the preceding 2 years; baccalaureate degree recommended but not required

Cost: ~$350 standard; ~$300 for ANNA/ASN/NKF/NOVA partner members (verify at nncc-exams.org)

Validity: 4 years; recertification via continuing education (contact hours) or re-examination

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About the Exam

The CDN validates specialized knowledge in dialysis nursing across all aspects of care for patients with kidney disease. Certified dialysis nurses work in hemodialysis units, peritoneal dialysis programs, acute dialysis, transplant centers, and home dialysis programs.

Exam Content Domains (per NNCC)

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Week-by-Week Study Plan

Weeks 1–2: Renal Anatomy, Physiology & CKD Foundations

Goal: Build strong nephrology knowledge base

Key Topics — Renal Anatomy & Physiology:

• •Kidney structure: cortex, medulla, renal pelvis; ~1 million nephrons per kidney
• •Nephron components: glomerulus, Bowman’s capsule, proximal convoluted tubule, loop of Henle, distal convoluted tubule, collecting duct
• •Renal blood flow: ~20–25% of cardiac output (1,200 mL/min)
• •Glomerular filtration: GFR (normal ~120 mL/min/1.73m²), filtration membrane
• •Tubular function: reabsorption and secretion
• •Hormonal functions:
• •Erythropoietin (EPO) — stimulates RBC production
• •Renin-angiotensin-aldosterone system (RAAS) — blood pressure regulation
• •Vitamin D activation (1,25-dihydroxyvitamin D / calcitriol)
• •Prostaglandins — renal blood flow regulation
• •Acid-base balance: bicarbonate reabsorption, hydrogen ion excretion
• •Electrolyte regulation: sodium, potassium, calcium, phosphorus, magnesium

Key Topics — CKD:

• •CKD Stages (KDIGO):
• •Stage 1: GFR ≥90 (normal/high) with kidney damage markers
• •Stage 2: GFR 60–89 (mildly decreased)
• •Stage 3a: GFR 45–59 (mild-moderate decrease)
• •Stage 3b: GFR 30–44 (moderate-severe decrease)
• •Stage 4: GFR 15–29 (severely decreased)
• •Stage 5: GFR <15 (kidney failure / ESKD)
• •Causes of CKD: diabetes mellitus (#1), hypertension (#2), glomerulonephritis, polycystic kidney disease
• •Uremic syndrome: signs and symptoms of toxin accumulation (nausea, pruritus, fatigue, pericarditis, encephalopathy, peripheral neuropathy)
• •Indications for dialysis initiation: refractory hyperkalemia, fluid overload unresponsive to diuretics, uremic symptoms, metabolic acidosis, pericarditis, declining nutritional status

Daily Schedule (2 hours/day):

• •Week 1, Days 1–3: Renal anatomy — structures, nephron, blood flow
• •Week 1, Days 4–5: Renal physiology — filtration, reabsorption, hormonal functions
• •Week 1, Days 6–7: Review & quiz (40 questions); reinforce with diagrams
• •Week 2, Days 1–3: CKD — stages, causes, progression, risk factors
• •Week 2, Days 4–5: Uremic syndrome — clinical manifestations, dialysis indications
• •Week 2, Days 6–7: Review & quiz (40 questions)

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Weeks 3–4: Hemodialysis — Principles, Access & Procedures

Goal: Master hemodialysis concepts and clinical procedures

Key Topics — Principles of Hemodialysis:

• •Diffusion: solute movement from high to low concentration across semipermeable membrane (removes BUN, creatinine, potassium, phosphate)
• •Ultrafiltration: fluid removal driven by transmembrane pressure (TMP)
• •Convection (hemodiafiltration): combined diffusive and convective clearance
• •Osmosis: water movement from low to high solute concentration
• •Dialysate composition: sodium (135–145 mEq/L), potassium (0–3 mEq/L), calcium (2.5–3.5 mEq/L), bicarbonate (30–40 mEq/L), glucose (100–200 mg/dL)
• •Kt/V and URR (Urea Reduction Ratio) — adequacy measures: target Kt/V ≥1.2 or URR ≥65%
• •Clearance concepts: small molecules (urea, creatinine) vs. middle molecules (beta-2 microglobulin)

Key Topics — Vascular Access:

• •AV Fistula (AVF): preferred access; artery-to-vein anastomosis; matures in 4–6 weeks; lowest complication rate; assess with thrill/bruit
• •AV Graft (AVG): synthetic conduit (ePTFE); can use in 2–4 weeks; higher infection/thrombosis rate than AVF
• •Central Venous Catheter (CVC): temporary or tunneled; highest infection risk; subclavian, jugular, or femoral placement
• •Tunneled (e.g., Permcath, Hickman) — long-term use
• •Non-tunneled — temporary (<3 weeks)
• •Access assessment: thrill (palpation), bruit (auscultation); inspect for redness, swelling, drainage, aneurysm, pseudoaneurysm
• •Cannulation techniques: rope-ladder, buttonhole, area (not recommended)
• •Access complications: infection, thrombosis, stenosis, steal syndrome, aneurysm/pseudoaneurysm, hematoma

Key Topics — Hemodialysis Procedure:

• •Pre-dialysis assessment: weight, vital signs, access site, edema, lung sounds, interdialytic weight gain (IDWG)
• •Machine setup: priming, testing, alarm settings
• •Treatment parameters: blood flow rate (typically 300–450 mL/min), dialysate flow rate (500–800 mL/min), treatment time (typically 3–4 hours), heparin dose
• •Intradialytic monitoring: vital signs every 30–60 minutes, monitoring for complications
• •Post-dialysis: assessment, needle removal, hemostasis, weight, vital signs

Key Topics — Hemodialysis Complications:

• •Hypotension (#1 most common): causes (excess ultrafiltration, low dialysate sodium, food intake, antihypertensives, cardiac dysfunction); treatment (Trendelenburg, normal saline bolus, reduce UF rate, stop UF)
• •Muscle cramps: related to volume depletion, low sodium; treatment (saline, hypertonic saline, reduce UF)
• •Disequilibrium syndrome: caused by rapid solute removal; headache, nausea, confusion, seizures; prevention (slower first treatment, shorter time, lower blood flow)
• •Hemolysis: machine malfunction, hypotonic dialysate; red/Porter wine–colored blood in lines
• •Air embolism: air in blood line; immediately clamp, position on left side with Trendelenburg, give O2
• •Pyrogenic reaction: contaminated dialysate; fever, chills, hypotension
• •Anaphylaxis/anaphylactoid reaction: hypersensitivity to dialyzer membrane or sterilant (ethylene oxide)
• •Heparin-induced complications: bleeding, heparin-induced thrombocytopenia (HIT)

Daily Schedule (2–3 hours/day):

• •Week 3, Days 1–3: Hemodialysis principles — diffusion, ultrafiltration, clearance, adequacy
• •Week 3, Days 4–5: Vascular access — types, assessment, cannulation, complications
• •Week 3, Days 6–7: Review & quiz (50 questions)
• •Week 4, Days 1–3: HD procedure — machine, parameters, pre/intra/post monitoring
• •Week 4, Days 4–5: HD complications — recognition, prevention, treatment
• •Week 4, Days 6–7: Review & quiz (50 questions); case studies

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Weeks 5–6: Peritoneal Dialysis, Pharmacology & Lab Values

Goal: Expand to PD and nephrology pharmacology

Key Topics — Peritoneal Dialysis (PD):

• •Principle: peritoneum acts as natural semipermeable membrane; dialysate infused into peritoneal cavity
• •Types:
• •CAPD (Continuous Ambulatory PD): manual exchanges, 4–5 exchanges/day, dwell 4–6 hours
• •APD (Automated PD/CCPD): cycler machine at night; typically 3–5 cycles
• •IPD (Intermittent PD): in-center, intermittent treatments
• •PD catheter: Tenckhoff catheter (most common); surgically placed, usually in lower abdomen
• •PD solutions: dextrose-based (1.5%, 2.5%, 4.25%) or icodextrin; contain sodium, calcium, magnesium, chloride, lactate/bicarbonate
• •Procedure: connection (aseptic technique), drain, fill, dwell, drain
• •Ultrafiltration in PD: higher dextrose concentration = more osmotic gradient = more fluid removal
• •PD adequacy: Kt/V ≥1.7/week (peritoneal + residual renal)
• •PD complications:
• •Peritonitis: cloudy effluent, abdominal pain, fever; diagnosis >100 WBC/μL with >50% PMNs; treatment (intraperitoneal antibiotics)
• •Exit site infection: redness, drainage at catheter exit
• •Tunnel infection: erythema, tenderness along subcutaneous tunnel
• •Catheter malfunction: malposition, fibrin, omental wrapping
• •Leaks: pericatheter, pleuroperitoneal
• •Hernias: umbilical, inguinal (increased intra-abdominal pressure)
• •Encapsulating peritoneal sclerosis (EPS): rare, serious late complication

Key Topics — Nephrology Pharmacology:

• •Erythropoiesis-Stimulating Agents (ESAs): epoetin alfa (Procrit/Epogen), darbepoetin (Aranesp); target Hgb 10–11.5 g/dL; monitor for hypertension, thrombosis
• •Iron supplementation: IV iron (iron sucrose, ferric gluconate, ferumoxytol) preferred in HD; target ferritin 200–500 ng/mL, TSAT 20–50%
• •Phosphate binders:
• •Calcium-based: calcium carbonate, calcium acetate (take with meals)
• •Non-calcium: sevelamer (Renvela), lanthanum (Fosrenol), sucroferric oxyhydroxide (Velphoro)
• •Vitamin D:
• •Active: calcitriol (Rocaltrol), paricalcitol (Zemplar), doxercalciferol
• •Target: calcium, phosphorus, and PTH within KDOQI ranges
• •Antihypertensives: ACE inhibitors, ARBs, beta-blockers, CCBs; hold before dialysis if causing intradialytic hypotension
• •Heparin: unfractionated heparin for HD anticoagulation; monitor ACT or PTT; dose adjustments for bleeding risk

Key Topics — Key Lab Values:

• •BUN: 10–20 mg/dL (pre-dialysis typically elevated)
• •Creatinine: 0.6–1.2 mg/dL (elevated in CKD)
• •Potassium: 3.5–5.0 mEq/L (hyperkalemia is dangerous in ESKD)
• •Calcium: 8.5–10.5 mg/dL
• •Phosphorus: 3.0–4.5 mg/dL (typically elevated in ESKD)
• •Intact PTH: 150–600 pg/mL (target in dialysis patients per KDOQI/KDIGO)
• •Albumin: ≥4.0 g/dL (nutritional marker; goal ≥3.5)
• •Hemoglobin/Hematocrit: target Hgb 10–11.5 g/dL (on ESA therapy)
• •TSAT: 20–50%; Ferritin: 200–500 ng/mL
• •Kt/V: ≥1.2; URR: ≥65%

Daily Schedule (2–3 hours/day):

• •Week 5, Days 1–3: Peritoneal dialysis — types, solutions, procedure, adequacy
• •Week 5, Days 4–5: PD complications — peritonitis, catheter issues, mechanical
• •Week 5, Days 6–7: Review & quiz (50 questions)
• •Week 6, Days 1–3: Pharmacology — ESAs, iron, phosphate binders, vitamin D
• •Week 6, Days 4–5: Lab values — interpretation, target ranges, nursing implications
• •Week 6, Days 6–7: Review & quiz (50 questions); pharmacology flashcards

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Weeks 7–8: Professional Issues, Special Populations & Comprehensive Review

Goal: Complete all domains; achieve exam readiness

Key Topics — Infection Control & Water Treatment:

• •Infection control in dialysis: standard precautions, isolation for bloodborne pathogens
• •Hepatitis B: separate machine and room for HBsAg+ patients; dedicated equipment; vaccination for all dialysis patients and staff
• •Hepatitis C: no separate machine required but use dedicated equipment; screening
• •Water treatment system: municipal water → carbon filtration → softening → reverse osmosis → distribution; AAMI standards (endotoxin <0.25 EU/mL, bacteria <200 CFU/mL)
• •Dialysate quality: regular culture and endotoxin testing
• •Dialyzer reprocessing: if used, must meet AAMI standards; single-use preferred in some settings

Key Topics — Special Populations:

• •Pediatric dialysis: weight-based dosing, growth and development considerations
• •Geriatric: increased fall risk, cognitive decline, polypharmacy, vascular access challenges
• •Diabetic patients: glucose monitoring (especially with peritoneal dialysis dextrose solutions), neuropathy assessment
• •Pregnancy in dialysis: intensified HD (6x/week), close monitoring
• •Acute kidney injury (AKI): different from CKD; may be reversible; continuous renal replacement therapy (CRRT) — CVVH, CVVHD, CVVHDF

Key Topics — Professional Issues:

• •Regulatory: CMS Conditions for Coverage for ESRD Facilities
• •Quality measures: Kt/V, URR, vascular access type, infection rates, hospitalization rates, patient satisfaction
• •Transplantation basics: living vs. deceased donor, evaluation process, immunosuppression, wait list management
• •Advance directives and palliative care in ESKD
• •Patient education: diet (low potassium, low phosphorus, fluid restriction, adequate protein), medication adherence, access care
• •Ethics: withholding/withdrawing dialysis, informed consent, quality of life
• •Documentation and scope of practice

Daily Schedule (2 hours/day):

• •Week 7, Days 1–2: Infection control, water treatment, dialyzer reprocessing
• •Week 7, Days 3–4: Special populations — pediatric, geriatric, diabetic, pregnant
• •Week 7, Days 5–6: Professional issues — CMS regulations, quality measures, transplant, ethics
• •Week 7, Day 7: Full-length practice exam #1; review incorrect answers
• •Week 8, Days 1–2: Targeted review of weakest domains
• •Week 8, Days 3–4: Full-length practice exam #2; review
• •Week 8, Days 5–6: Final review — key lab values, pharmacology, access types, complications
• •Week 8, Day 7: REST. You’re ready.

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Test-Taking Tips

1. Patient safety first — in emergency situations, choose the intervention that protects the patient
2. Know HD complications cold — hypotension is the most common; know causes and interventions for each
3. Access questions are heavily tested — know AVF > AVG > CVC in terms of preference and infection risk
4. Lab value interpretation — know target ranges for dialysis patients (which differ from general population)
5. PD peritonitis — cloudy effluent = peritonitis until proven otherwise; know diagnosis and treatment
6. Pharmacology is high-yield — know drug classes, purposes, key side effects, and monitoring parameters
7. Adequacy measures — Kt/V ≥1.2 (HD) and ≥1.7/week (PD); URR ≥65%
8. Water quality matters — know AAMI standards and the treatment process
9. Time management — 150 questions in 3 hours = 1.2 minutes per question
10. Don’t second-guess unless you clearly misread the question

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Recommended Resources

Primary:

• •NNCC CDN Candidate Handbook and Exam Content Outline (nncc-exams.org)
• •Core Curriculum for Nephrology Nursing — American Nephrology Nurses Association (ANNA)
• •Nephrology Nursing Standards of Practice and Standards of Professional Performance — ANNA

Supplementary:

• •Nephrology and Dialysis Therapy — Daugirdas, Blake, Ing (Handbook of Dialysis, 5th ed)
• •Brenner and Rector’s The Kidney — for in-depth renal physiology
• •ANNA Clinical Practice Guidelines
• •KDIGO Clinical Practice Guidelines (kdigo.org — free)

Free Resources:

• •KDIGO Guidelines (kdigo.org)
• •CMS Conditions for Coverage for ESRD Facilities
• •Fresenius Medical Care and DaVita patient/staff education materials
• •ANNA educational webinars and resources (annanurse.org)

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Sources

• •Nephrology Nursing Certification Commission (NNCC) — nncc-exams.org
• •NNCC CDN Examination Content Outline
• •American Nephrology Nurses Association (ANNA) — annanurse.org
• •KDIGO (Kidney Disease: Improving Global Outcomes) Clinical Practice Guidelines
• •National Kidney Foundation KDOQI Guidelines
• •CMS Conditions for Coverage for ESRD Facilities (42 CFR Part 494)
• •Daugirdas, J.T. et al. Handbook of Dialysis, 5th Edition
• •AAMI Standards for Dialysate (RD62:2001/A1:2007)