Document:

<PAGE>
                                                                     EXHIBIT 4.3

                          SECOND SUPPLEMENTAL INDENTURE

          Supplemental Indenture (this "Supplemental Indenture"), dated as of
April 30, 2004 among the entities listed in Exhibit A hereto (each a
"Guaranteeing Subsidiary" and together the "Guaranteeing Subsidiaries"), each a
subsidiary of Renal Care Group, Inc., Renal Care Group, Inc. (as successor to
National Nephrology Associate, Inc.), a Delaware corporation (the "Company"),
the Guarantors (as defined in the Indenture referred to herein) and Wells Fargo
Bank, National Association, a national banking association (as successor by
merger to Wells Fargo Bank Minnesota, N.A.), as trustee under the Indenture
referred to below (the "Trustee").

                               W I T N E S S E T H

          WHEREAS, the Company has heretofore become a party to an indenture
(the "Indenture"), dated as of October 22, 2003 providing for the issuance of 9%
Senior Subordinated Notes due 2011 (the "Notes");

          WHEREAS, the Indenture provides that under certain circumstances the
Guaranteeing Subsidiaries shall execute and deliver to the Trustee a
supplemental indenture pursuant to which each Guaranteeing Subsidiary shall
unconditionally guarantee all of the Company's obligations under the Notes and
the Indenture on the terms and conditions set forth herein (the "Guarantee");
and

          WHEREAS, pursuant to Section 9.01 of the Indenture, the Trustee is
authorized to execute and deliver this Supplemental Indenture.

          NOW THEREFORE, in consideration of the foregoing and for other good
and valuable consideration, the receipt of which is hereby acknowledged, each
Guaranteeing Subsidiary and the Trustee mutually covenant and agree for the
equal and ratable benefit of the Holders of the Notes as follows:

          1. Capitalized Terms. Capitalized terms used herein without definition
shall have the meanings assigned to them in the Indenture.

          2. Agreement to Guarantee. Each Guaranteeing Subsidiary hereby agrees
as follows:

          (a)  Along with all other Guarantors, to jointly and severally
Guarantee to each Holder of a Note authenticated and delivered by the Trustee
and to the Trustee and its successors and assigns, irrespective of the validity
and enforceability of the Indenture, the Notes or the obligations of the Company
hereunder or thereunder, that:

               (i)  the principal of and interest on the Notes will be promptly
          paid in full when due, whether at maturity, by acceleration,
          redemption or otherwise, and interest on the overdue principal of and
          interest on the Notes, if any, if lawful, and all other obligations of
          the Company to the Holders or the Trustee hereunder or thereunder will
          be promptly paid in full or performed, all in accordance with the
          terms hereof and thereof; and

                                       1
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               (ii) in case of any extension of time of payment or renewal of
          any Notes or any of such other obligations, the same will be promptly
          paid in full when due or performed in accordance with the terms of the
          extension or renewal, whether at stated maturity, by acceleration or
          otherwise. Failing payment when due of any amount so guaranteed or any
          performance so guaranteed for whatever reason, the Guarantors shall be
          jointly and severally obligated to pay the same immediately.

          (b)  The obligations hereunder shall be unconditional, irrespective of
     the validity, regularity or enforceability of the Notes or the Indenture,
     the absence of any action to enforce the same, any waiver or consent by any
     Holder of the Notes with respect to any provisions hereof or thereof, the
     recovery of any judgment against the Company, any action to enforce the
     same or any other circumstance that might otherwise constitute a legal or
     equitable discharge or defense of a guarantor.

          (c)  The following are hereby waived: diligence, presentment, demand
     of payment, filing of claims with a court in the event of insolvency or
     bankruptcy of the Company, any right to require a proceeding first against
     the Company, protest, notice and all demands whatsoever.

          (d)  This Guarantee shall not be discharged except by complete
     performance of the obligations contained in the Notes and the Indenture.

          (e)  If any Holder or the Trustee is required by any court or
     otherwise to return to the Company, the Guarantors, or any Custodian,
     Trustee, liquidator or other similar official acting in relation to either
     the Company or the Guarantors, any amount paid by either to the Trustee or
     such Holder, this Guarantee, to the extent theretofore discharged, shall be
     reinstated in full force and effect.

          (f)  Such Guaranteeing Subsidiary shall not be entitled to any right
     of subrogation in relation to the Holders in respect of any obligations
     guaranteed hereby until payment in full of all obligations guaranteed
     hereby.

          (g)  As between the Guarantors, on the one hand, and the Holders and
     the Trustee, on the other hand, (x) the maturity of the obligations
     guaranteed hereby may be accelerated as provided in Article Six of the
     Indenture for the purposes of this Guarantee, notwithstanding any stay,
     injunction or other prohibition preventing such acceleration in respect of
     the obligations guaranteed hereby, and (y) in the event of any declaration
     of acceleration of such obligations as provided in Article Six of the
     Indenture, such obligations (whether or not due and payable) shall
     forthwith become due and payable by the Guarantors for the purpose of this
     Guarantee.

          (h)  Pursuant to Section 10.02 of the Indenture, after giving effect
to any maximum amount and any other contingent and fixed liabilities that are
relevant under any applicable Bankruptcy or fraudulent conveyance laws, and
after giving effect to any collections from, rights to receive contribution from
or payments made by or on behalf of any other Guarantor in respect of the
obligations of such other Guarantor under Article Ten of the Indenture shall
result in the obligations of such Guarantor under its Guarantee not constituting
a fraudulent transfer or conveyance.

                                       2
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          3. Subordination. The Obligations of the Guaranteeing Subsidiary under
its Guarantee pursuant to this Supplemental Indenture shall be junior and
subordinated to the Senior Indebtedness of the Guaranteeing Subsidiary on the
same basis as the Notes are junior and subordinated to the Senior Indebtedness
of the Company. For the purposes of the foregoing sentence, the Trustee and the
Holders shall have the right to receive and/or retain payments by the
Guaranteeing Subsidiary only at such time as they may receive and/or retain
payments in respect of the Notes pursuant to the Indenture, including Article
Ten thereof.

          4. Execution and Delivery. Each Guaranteeing Subsidiary agrees that
the Guarantees shall remain in full force and effect notwithstanding any failure
to endorse on each Note a notation of such Guarantee.

          5. Guaranteeing Subsidiary May Consolidate, Etc., on Certain Terms.

          Except as otherwise provided in Section 11.05 of the Indenture, a
Guarantor may not consolidate with or merge with or into any other Person or
convey, sell, assign, transfer, lease or otherwise dispose of its properties and
assets substantially as an entirety to any other Person (other than the Company
or another Guarantor) unless:

          (i)  subject to the provisions of the following paragraph, the Person
formed by or surviving such consolidation or merger (if other than such
Guarantor) or to which such properties and assets are transferred assumes all of
the obligations of such Guarantor under this Indenture and its Guarantee,
pursuant to a supplemental indenture in form and substance satisfactory to the
Trustee;

          (j)  immediately after giving effect to such transaction, no Default
or Event of Default has occurred and is continuing; and

          (k)  the Guarantor delivers, or causes to be delivered, to the
Trustee, in form and substance reasonably satisfactory to the Trustee, an
Officers' Certificate and an Opinion of Counsel, each stating that such
transaction complies with the requirements of this Indenture.

          For purposes of the foregoing, the transfer (by lease, assignment,
sale or otherwise, in a single transaction or series of transactions) of all or
substantially all of the properties or assets of one or more Restricted
Subsidiaries, the Capital Stock of which constitutes all or substantially all of
the properties and assets of the Company, shall be deemed to be the transfer of
all or substantially all of the properties and assets of the Company.

          In case of any such consolidation, merger, sale or conveyance and upon
the assumption by the successor Person, by supplemental indenture, executed and
delivered to the Trustee and reasonably satisfactory in form to the Trustee, of
the Guarantee endorsed upon the Notes and the due and punctual performance of
all of the covenants and conditions of the Indenture to be performed by a
Guarantor, such successor Person shall succeed to and be substituted for a
Guarantor with the same effect as if it had been named herein as a Guarantor.
Such successor Person thereupon may cause to be signed any or all of the
Guarantees to be endorsed upon all of the Notes issuable hereunder which
theretofore shall not have been signed by the Company and delivered to the
Trustee. All the Guarantees so issued shall in all respects have the same legal
rank and benefit under the Indenture as the Guarantees theretofore and
thereafter issued in accordance

                                       3
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with the terms of the Indenture as though all of such Guarantees had been issued
at the date of the execution hereof.

          6.   Releases.

          (a)  A Guarantor will be deemed automatically and unconditionally
released and discharged from all of its obligations under its Guarantee without
any further action on the part of the Trustee or any Holder of the Notes upon a
sale or other disposition to a Person not an Affiliate of the Company of all of
the Capital Stock of, or all or substantially all of the assets of, such
Guarantor, by way of merger, consolidation or otherwise, which transaction is
carried out in accordance with Section 4.10 hereof; provided that any such
termination shall occur (x) only to the extent that all obligations of such
Guarantor under all of its guarantees of, and under all of its pledges of assets
or other security interests which secure any Indebtedness of the Company shall
also terminate upon such sale, disposition or release and (y) only if the
Trustee is furnished with written notice of such release together with an
Officers' Certificate from such Guarantor to the effect that all of the
conditions to release in this Section 6 have been satisfied.

          (b) Any Guarantor not released from its obligations under its
Guarantee shall remain liable for the full amount of principal of and interest
on the Notes and for the other obligations of any Guarantor under the Indenture
as provided in Article Eleven of the Indenture.

          7. No Recourse Against Others. No director, officer, employee,
incorporator or stockholder of the Company or any Guarantor, as such, shall have
any liability for any obligations of the Company or the Guarantors under the
Notes, this Indenture, the Guarantees or for any claim based on, in respect of,
or by reason of, such obligations or their creation. Each Holder of Notes by
accepting a Note waives and releases all such liability. The waiver and release
are part of the consideration for issuance of the Notes. The waiver may not be
effective to waive liabilities under the federal securities laws.

          8. NEW YORK LAW TO GOVERN. THE INTERNAL LAW OF THE STATE OF NEW YORK
SHALL GOVERN AND BE USED TO CONSTRUE THIS SUPPLEMENTAL INDENTURE BUT WITHOUT
GIVING EFFECT TO APPLICABLE PRINCIPLES OF CONFLICTS OF LAW TO THE EXTENT THAT
THE APPLICATION OF THE LAWS OF ANOTHER JURISDICTION WOULD BE REQUIRED THEREBY.

          9. Counterparts. The parties may sign any number of copies of this
Supplemental Indenture. Each signed copy shall be an original, but all of them
together represent the same agreement.

          10. Effect of Headings. The Section headings herein are for
convenience only and shall not affect the construction hereof.

          11. Trustee. The Trustee shall not be responsible in any manner
whatsoever for or in respect of the validity or sufficiency of this Supplemental
Indenture or for or in respect of the recitals contained herein, all of which
recitals are made solely by the Guaranteeing Subsidiary and the Company.

                                       4
<PAGE>

          IN WITNESS WHEREOF, the parties hereto have caused this Supplemental
Indenture to be duly executed and attested, all as of the date first above
written.

Dated: April 30, 2004

                              GUARANTEEING SUBSIDIARIES:

                              RENAL CARE GROUP EAST, INC., a Pennsylvania
                                corporation
                              RENAL CARE GROUP MICHIGAN, INC., a Delaware
                                corporation
                              MICHIGAN HOME DIALYSIS CENTER, INC., a Michigan
                                corporation
                              RENAL CARE GROUP OF THE MIDWEST, INC., a Kansas
                                corporation
                              FOUR STATE REGIONAL DIALYSIS CENTER, INC., a
                                Missouri corporation
                              FORT SCOTT REGIONAL DIALYSIS CENTER, INC., a
                                Missouri corporation
                              MIAMI REGIONAL DIALYSIS CENTER, INC., a Missouri
                                corporation
                              RCG MISSISSIPPI, INC., a Delaware corporation
                              RENAL CARE GROUP OF THE SOUTHEAST, INC., a Florida
                                corporation
                              NORTHEAST ALABAMA KIDNEY CLINIC, INC., an Alabama
                                corporation
                              RENAL CARE GROUP TEXAS, INC., a Texas corporation
                              DIALYSIS MANAGEMENT CORPORATION, a Texas
                                corporation
                              RCG PA MERGER CORP., a Texas corporation
                              STAT DIALYSIS CORPORATION, a Delaware corporation
                              ANGLETON DIALYSIS, INC., a Texas corporation
                              BRAZORIA KIDNEY CENTER, INC., a Texas corporation
                              FONDREN DIALYSIS CLINIC, INC., a Texas corporation
                              WHARTON DIALYSIS, INC., a Texas corporation
                              JEFFERSON COUNTY DIALYSIS, INC., an Arkansas
                                corporation
                              KDCO, INC., a Missouri corporation

                              By: /s/ Douglas B. Chappell
                                  ----------------------------------------------
                              Name:  Douglas B. Chappell
                              Title: Vice President and Secretary

                                       5
<PAGE>

GUARANTEEING                  LAWTON DIALYSIS, INC., an Arkansas corporation
SUBSIDIARIES (CONTINUED):     LITTLE ROCK DIALYSIS, INC., an Arkansas
                                corporation
                              NORTHWEST DIALYSIS, INC., an Arkansas corporation
                              RENALAB, INC., a Delaware corporation
                              RCG FINANCE, INC., a Delaware corporation
                              RENALPARTNERS, INC., a Delaware corporation
                              RENALNET, INC., a Delaware corporation
                              WOUND CARE GROUP, INC., a Delaware corporation
                              DIABETES CARE GROUP, INC., a Delaware corporation
                              RENAL CARE GROUP ARIZONA, INC., an Arizona
                                corporation
                              RENAL CARE GROUP NORTHWEST, INC., a Delaware
                                corporation
                              RENALNET, ARIZONA, INC., an Arizona corporation
                              RCG UNIVERSITY DIVISION, INC., a Tennessee
                                corporation
                              R.C.G. SUPPLY COMPANY, a Tennessee corporation
                              RENAL CARE GROUP ALASKA, INC., an Alaska
                                corporation
                              RENAL CARE GROUP SOUTHWEST HOLDINGS, INC., a
                                Delaware corporation
                              DIALYSIS CENTERS OF AMERICA - ILLINOIS, INC., an
                                Illinois corporation
                              SSKG, INC., an Illinois corporation
                              RENAL CARE GROUP OHIO, INC., a Delaware
                                corporation
                              PHYSICIANS DIALYSIS COMPANY, INC., a Pennsylvania
                                corporation
                              KENTUCKY RENAL CARE GROUP, LLC, a Delaware limited
                                liability company

                              By: /s/ Douglas B. Chappell
                                  ----------------------------------------------
                              Name:  Douglas B. Chappell
                              Title: Vice President and Secretary

                              DIALYSIS LICENSING CORP., a Delaware corporation
                              RCGIH, INC., a Delaware corporation

                              By: /s/ Douglas B. Chappell
                                  ----------------------------------------------
                              Name:  Douglas B. Chappell
                              Title: Vice President and Assistant Secretary

                                       6
<PAGE>

GUARANTEEING                RENAL CARE GROUP SOUTHWEST, L.P., a Delaware
SUBSIDIARIES (CONTINUED):     limited partnership

                              By: Renal Care Group Arizona, Inc., as sole
                                  general partner

                              By: /s/ Douglas B. Chappell
                                 -----------------------------------------------
                              Name:  Douglas B. Chappell
                              Title: Vice President and Secretary

                            ARIZONA RENAL INVESTMENTS, LLC, a Delaware limited
                              liability company
                              By: Renal Care Group Arizona, Inc., as sole member

                              By: /s/ Douglas B. Chappell
                                 -----------------------------------------------
                              Name:  Douglas B. Chappell
                              Title: Vice President and Secretary

                            RCG INDIANA, L.L.C., a Delaware limited liability
                              company
                              By: Renal Care Group, Inc., as manager

                              By: /s/ Douglas B. Chappell
                                 -----------------------------------------------
                              Name:  Douglas B. Chappell
                              Title: Senior Vice President and Secretary

                            KIDNEY DISEASE CENTER OF THE OZARKS, L.L.C., a
                              Missouri limited liability company
                              By: Renal Care Group, Inc., as sole member

                              By: /s/ Douglas B. Chappell
                                 -----------------------------------------------
                              Name:  Douglas B. Chappell
                              Title: Senior Vice President and Secretary

                                       7
<PAGE>

GUARANTEEING                STUTTGART DIALYSIS, LLC, an Arkansas limited
SUBSIDIARIES (CONTINUED):     liability company
                              By: Renal Care Group, Inc., as sole manager

                              By: /s/ Douglas B. Chappell
                                 -----------------------------------------------
                              Name:  Douglas B. Chappell
                              Title: Senior Vice President and Secretary

                            RCG WEST HEALTH SUPPLY, L.C., an Arizona limited
                              company
                              By: Renal Care Group, Inc., as member

                              By: /s/ Douglas B. Chappell
                                 -----------------------------------------------
                              Name:  Douglas B. Chappell
                              Title: Senior Vice President and Secretary

                            RENAL CARE GROUP TEXAS, LP, a Delaware limited
                              partnership
                              By: RCG PA Merger Corp., as sole general partner

                              By: /s/ Douglas B. Chappell
                                 -----------------------------------------------
                              Name:  Douglas B. Chappell
                              Title: Vice President and Secretary

                            RENAL CARE GROUP WESTLAKE, LLC, a Delaware limited
                              liability company
                              By: RCG University Division, Inc., as sole member

                              By: /s/ Douglas B. Chappell
                                 -----------------------------------------------
                              Name:  Douglas B. Chappell
                              Title: Vice President and Secretary

                                       8
<PAGE>

                              RENAL CARE GROUP, INC.

                              By: /s/ David M. Dill
                                 -----------------------------------------------
                              Name: David M. Dill
                              Title: Executive Vice President

                                       9
<PAGE>

                              EXISTING GUARANTORS:

                              NNA OF OKLAHOMA, INC., a Nevada corporation
                              NNA OF GEORGIA, INC., a Delaware corporation
                              NNA OF ALABAMA, INC., an Alabama corporation
                              NNA MANAGEMENT COMPANY OF KENTUCKY, INC., a
                               Kentucky corporation
                              NATIONAL NEPHROLOGY ASSOCIATES MANAGEMENT COMPANY
                                OF TEXAS, INC., a Texas corporation
                              NNA OF NEVADA, INC., a Nevada corporation
                              NATIONAL NEPHROLOGY ASSOCIATES CREDIT CORPORATION,
                                a Tennessee corporation
                              NNA OF TOLEDO, INC., an Ohio corporation
                              NNA PROPERTIES OF NEW JERSEY, INC., a New Jersey
                                corporation
                              NNA MANAGEMENT COMPANY OF LOUISIANA, INC., a
                                Louisiana corporation
                              RENEX CORP., a Florida corporation
                              RENEX MANAGEMENT SERVICES, INC., a Florida
                                corporation
                              DIALYSIS SERVICES OF ATLANTA, INC., a Georgia
                                corporation
                              RENEX DIALYSIS CLINIC OF PENN HILLS, INC., a
                                Pennsylvania corporation
                              RENEX DIALYSIS CLINIC OF SHALER, INC., a
                                Pennsylvania corporation
                              RENEX DIALYSIS CLINIC OF DOYLESTOWN, INC., a
                                Pennsylvania corporation
                              RENEX DIALYSIS CLINIC OF AMESBURY, INC., a
                                Massachusetts corporation
                              RENEX DIALYSIS CLINIC OF NORTH ANDOVER, INC., a
                                Massachusetts corporation
                              RENEX DIALYSIS CLINIC OF SOUTH GEORGIA, INC., a
                                Georgia corporation
                              RENEX DIALYSIS CLINIC OF CREVE COUER, INC., a
                                Missouri corporation
                              RENEX DIALYSIS CLINIC OF ST. LOUIS, INC., a
                                Missouri corporation

                              By:  /s/ David M. Dill
                                 -----------------------------------------------
                              Name:  David M. Dill
                              Title: Vice President

                                       10
<PAGE>

EXISTING GUARANTORS           RENEX DIALYSIS CLINIC OF BRIDGETON, INC., a
(CONTINUED):                    Missouri corporation
                              RENEX DIALYSIS CLINIC OF UNION, INC., a Missouri
                                corporation
                              RENEX DIALYSIS HOMECARE OF GREATER ST. LOUIS,
                                INC., a Missouri corporation
                              RENEX DIALYSIS CLINIC OF MAPLEWOOD, INC., a
                                Missouri corporation
                              RENEX DIALYSIS CLINIC OF UNIVERSITY CITY, INC., a
                                Missouri corporation
                              RENEX DIALYSIS FACILITIES, INC., a Mississippi
                                corporation
                              RENEX DIALYSIS CLINIC OF BLOOMFIELD, INC., a New
                                Jersey corporation
                              RENEX DIALYSIS CLINIC OF ORANGE, INC., a New
                                Jersey corporation
                              RENEX DIALYSIS CLINIC OF PHILADELPHIA, INC., a
                                Pennsylvania corporation
                              RENEX DIALYSIS CLINIC OF PITTSBURGH, INC., a
                                Pennsylvania corporation
                              RENEX DIALYSIS CLINIC OF WOODBURY, INC., a New
                                Jersey corporation
                              RENEX DIALYSIS CLINIC OF TAMPA, INC., a Florida
                                corporation
                              NNA PROPERTIES OF KENTUCKY, INC., a Kentucky
                                corporation
                              NNA PROPERTIES OF TENNESSEE, INC., a Tennessee
                                corporation
                              NNA TRANSPORTATION SERVICES CORPORATION, a
                                Tennessee corporation

                              By:  /s/ David M. Dill
                                 -----------------------------------------------
                              Name:  David M. Dill
                              Title: Vice President

                              NATIONAL NEPHROLOGY ASSOCIATES OF TEXAS, L.P., a
                                Texas limited partnership
                                By: National Nephrology Associates Management
                                    Company of Texas, Inc., a Texas corporation,
                                    as general partner

                                By:  /s/ David M. Dill
                                   ----------------------------------------
                                Name:  David M. Dill
                                Title: Vice President

                                       11
<PAGE>

EXISTING GUARANTORS           NNA - SAINT BARNABAS, L.L.C., a New Jersey limited
(CONTINUED):                    liability company
                                By: Renex Dialysis Clinic of Woodbury Inc., a
                                    Delaware corporation, as sole member

                              NNA - SAINT BARNABAS - LIVINGSTON, L.L.C., a New
                                Jersey limited liability company
                                By: NNA - Saint Barnabas, LLC, a New Jersey
                                    limited liability company, as sole member
                                    By: Renex Dialysis Clinic of Woodbury Inc.,
                                        a Delaware corporation, as sole member

                              NNA OF OKLAHOMA, L.L.C., an Oklahoma limited
                                liability company
                                By: NNA of Oklahoma, Inc., a Nevada corporation,
                                    as sole member

                              NNA OF LOUISIANA, LLC, a Louisiana limited
                                liability company
                                By: NNA Management Company of Louisiana, Inc.,
                                    as sole member

                              DOYLESTOWN ACUTE RENAL SERVICES, L.L.C., a
                                Pennsylvania limited liability company
                                By: Renex Dialysis Clinic of Doylestown, Inc., a
                                    Pennsylvania corporation, as sole member

                              NNA OF NEWARK, L.L.C., a New Jersey limited
                                liability company
                                By: Renex Dialysis Clinic of Woodbury, Inc., a
                                    New Jersey corporation, as sole member

                              By: /s/ David M. Dill
                                 -----------------------------------------------
                              Name:  David M. Dill
                              Title: Vice President

                              NNA OF RHODE ISLAND, INC., a Rhode Island
                                corporation

                                By: /s/ Leif Murphy
                                   -----------------------------------------
                                Name:  Leif Murphy
                                Title: Executive Vice President

                                       12
<PAGE>

EXISTING GUARANTORS           DIALYSIS ASSOCIATES, LLC, a Tennessee limited
(CONTINUED):                    liability company
                              DIALYSIS ASSOCIATES MEDICAL SUPPLY, LLC, a
                                Tennessee limited liability company
                                By: Renal Care Group, Inc., a Delaware
                                    corporation, as sole member

                                By: /s/ David M. Dill
                                   ----------------------------------------
                                Name:  David M. Dill
                                Title: Executive Vice President and
                                       Chief Financial Officer

                                       13
<PAGE>

                              WELLS FARGO BANK MINNESOTA, N.A., AS TRUSTEE

                              By: /s/ Jane Y. Schweiger
                                  ----------------------------------------------
                              Name:  Jane Y. Schweiger
                              Title: Vice President

                                       14
<PAGE>
                                    EXHIBIT A

                            Guaranteeing Subsidiaries

Renal Care Group East, Inc.
Renal Care Group Michigan, Inc.
Michigan Home Dialysis Center, Inc.
Renal Care Group of the Midwest, Inc.
Four State Regional Dialysis Center, Inc.
Fort Scott Regional Dialysis Center, Inc.
Miami Regional Dialysis Center, Inc.
RCG Mississippi, Inc.
Renal Care Group of the Southeast, Inc.
Northeast Alabama Kidney Clinic, Inc.
Renal Care Group Texas, Inc.
Dialysis Management Corporation
RCG PA Merger Corp.
STAT Dialysis Corporation
Angleton Dialysis, Inc.
Brazoria Kidney Center, Inc.
Fondren Dialysis Clinic, Inc.
Wharton Dialysis, Inc.
Jefferson County Dialysis, Inc.
KDCO, Inc.
Lawton Dialysis, Inc.
Little Rock Dialysis, Inc.
Northwest Dialysis, Inc.
RenaLab, Inc.
RCG Finance, Inc.
RenalPartners, Inc.
RenalNet, Inc.
Wound Care Group, Inc.
Diabetes Care Group, Inc.
Renal Care Group Arizona, Inc.
Renal Care Group Northwest, Inc.
RenalNet, Arizona, Inc.
RCG University Division, Inc.
R.C.G. Supply Company
Renal Care Group Alaska, Inc.
Renal Care Group Southwest Holdings, Inc.
Dialysis Centers of America - Illinois, Inc.
SSKG, Inc.
Renal Care Group Ohio, Inc.
Physicians Dialysis Company, Inc.
Dialysis Licensing Corp.
RCGIH, Inc.

                                      -A1-
<PAGE>

Renal Care Group Southwest, L.P.
Arizona Renal Investments, LLC
RCG Indiana, L.L.C.
Kidney Disease Center of the Ozarks, L.L.C.
Stuttgart Dialysis, LLC
RCG West Health Supply, L.C.
Kentucky Renal Care Group, LLC
Renal Care Group Texas, LP
Renal Care Group Westlake, LLC

                                      -A2-<PAGE>
                                                                    EXHIBIT 4.1

                      FOURTH AMENDMENT TO CREDIT AGREEMENT

         THIS FOURTH AMENDMENT TO CREDIT AGREEMENT is dated as of December 7,
2004 (the "AMENDMENT"), by and among ROCK-TENN COMPANY, a Georgia corporation
(the "BORROWER"), SUNTRUST BANK, a banking corporation organized under the laws
of the State of Georgia ("SUNTRUST"), the other banks and financial
institutions listed on the signature pages hereof (SunTrust and such other
banks, lending institutions and assignees thereof referred to collectively
herein as the "LENDERS"), SUNTRUST BANK, in its capacity as Agent for the
Lenders (the "AGENT"), BANK OF AMERICA, N.A., as Syndication Agent (the
"SYNDICATION AGENT") and WACHOVIA BANK, N.A., as Documentation Agent (the
"DOCUMENTATION AGENT").

         WHEREAS, the Borrower, the Agent, the Syndication Agent, the
Documentation Agent and the Lenders are parties to that certain Credit
Agreement dated as of June 30, 2000, as amended by that certain First Amendment
to Credit Agreement dated as of April 6, 2001, that certain Second Amendment to
Credit Agreement dated as of July 26, 2001, and that certain Third Amendment to
Credit Agreement dated as of March 31, 2003 (as amended, the "CREDIT
AGREEMENT"; all capitalized terms not otherwise defined herein shall have the
meanings set forth in the Credit Agreement), pursuant to which the Lenders have
made available certain financial accommodations to the Borrower; and

         WHEREAS, the parties wish to amend the Credit Agreement on the terms
and conditions contained herein;

         NOW, THEREFORE, for good and valuable consideration, the receipt and
sufficiency of which are hereby acknowledged by the parties hereto, the parties
hereto agree as follows:

         Section 1. Amendment. The Credit Agreement is hereby amended by
deleting the definition of "MATURITY DATE" from Section 1.1 and substituting in
lieu thereof the following new definition of "MATURITY DATE":

         "MATURITY DATE" shall mean the earlier of (i) June 30, 2006, and (ii)
         the date on which all amounts outstanding under this Agreement have
         been declared or have automatically become due and payable pursuant to
         the provisions of Article 9.

         Section 2. Benefits of Credit Documents. Each reference to the Credit
Agreement in any of the Credit Documents shall be deemed to be a reference to
the Credit Agreement as amended by this Amendment, and as the Credit Agreement
may from time to time be further amended, supplemented, restated or otherwise
modified in the future by one or more other written amendments or supplemental
or modification agreements entered into pursuant to the applicable provisions
thereof.

<PAGE>
         Section 3. Conditions to Effectiveness of Amendment. The effectiveness
of this Amendment is subject to the following conditions precedent:

                  (a)      that each of the following be received by the Agent
(unless otherwise waived in writing by the Agent), each of which shall be
satisfactory in form and substance to the Agent:

                           (1)      this Amendment executed by the Borrower and
by the Required Lenders,

                           (2)      the Acknowledgment and Consent of the
Guarantors, substantially in the form of Exhibit A hereto, executed by each of
the Guarantors (as defined below) (the "ACKNOWLEDGMENT"),

                           (3)      payment by the Borrower to the Agent of any
expenses incurred by the Agent which are due and payable, and

                           (4)      such other approvals, opinions or documents
as the Agent may reasonably request; and

                  (b)      no Default or Event of Default shall then be in
existence.

         Section 4. Representations. The Borrower represents to the Lenders
that:

                  (a)      the Borrower has the right and power, and has taken
all necessary action to authorize it, to execute and deliver this Amendment,
and to perform this Amendment, the Credit Agreement, as amended by this
Amendment, and the other Credit Documents in accordance with their respective
terms. This Amendment has been duly executed and delivered by the duly
authorized officers of the Borrower, and each of this Amendment, the Credit
Agreement, as amended by this Amendment, and the other Credit Documents to
which the Borrower is a party is a legal, valid and binding obligation of the
Borrower enforceable against the Borrower in accordance with its terms, except
as may be limited by applicable bankruptcy, insolvency, reorganization,
moratorium, or similar laws affecting the enforcement of creditors' rights
generally and by general principles of equity.

                  (b)      the execution and delivery of this Amendment, and
the performance by the Borrower of this Amendment, and the Credit Agreement, as
amended by this Amendment, in accordance with their respective terms, do not
and will not, by the passage of time or the giving of notice, or otherwise: (i)
violate any Requirement of Law relating to the Borrower; (ii) conflict with,
result in a breach of or constitute a default under the charter or by-laws of
the Borrower or any of its Material Contractual Obligations; or (iii) result in
or require the creation or imposition of any Lien upon or with respect to any
property now owned or hereafter acquired by the Borrower other than those
permitted by the Credit Agreement.

                  (c)      the articles of incorporation and bylaws of the
Borrower have not changed since delivery of such articles of incorporation and
bylaws to the Lenders in connection with the consummation of the Credit
Agreement.

                                      -2-
<PAGE>
         Section 5. Reaffirmation. The Borrower hereby repeats and reaffirms
all representations and warranties made by the Borrower in the Credit Agreement
and the other Credit Documents to which it is a party as of the date hereof
with the same force and effect as if such representations and warranties were
set forth in this Amendment in full except to the extent such representations
expressly relate to an earlier date or have been updated to the extent
permitted by the Credit Agreement.

         Section 6. Reaffirmation and Representations by Guarantors. By
execution of the Acknowledgment, each Subsidiary that has executed a Subsidiary
Guarantee (a "GUARANTOR"):

                  (a)      reaffirms its continuing obligations to the Agent
and the Lenders under the Subsidiary Guarantee to which it is a party and
agrees that the transactions contemplated by this Amendment shall not in any
way affect the validity and enforceability of such Subsidiary Guarantee or
reduce, impair or discharge the obligations of such Guarantor thereunder; and

                  (b)      represents to the Lenders that:

                           (1)      such Guarantor has the right and power, and
has taken all necessary action to authorize it, to execute and deliver the
Acknowledgement, and to perform the Acknowledgement in accordance with its
terms. The Acknowledgement has been duly executed and delivered by the duly
authorized officers of such Guarantor, and the Acknowledgement is a legal,
valid and binding obligation of such Guarantor enforceable against such
Guarantor in accordance with its terms, except as may be limited by applicable
bankruptcy, insolvency, reorganization, moratorium, or similar laws affecting
the enforcement of creditors' rights generally and by general principles of
equity; and

                           (2)      the execution and delivery of the
Acknowledgement, and the performance by such Guarantor of the Acknowledgement,
do not and will not, by the passage of time or the giving of notice, or
otherwise: (i) violate any Requirement of Law relating to such Guarantor; (ii)
conflict with, result in a breach of or constitute a default under the charter
or by-laws of such Guarantor, or any of its Material Contractual Obligations;
or (iii) result in or require the creation or imposition of any Lien upon or
with respect to any property now owned or hereafter acquired by such Guarantor
other than those permitted by the Credit Agreement.

         Section 7. Benefits. This Amendment shall be binding upon and shall
inure to the benefit of the parties hereto and their respective successors and
assigns.

         Section 8. GOVERNING LAW. THIS AMENDMENT SHALL BE GOVERNED BY, AND
CONSTRUED IN ACCORDANCE WITH, THE LAWS OF THE STATE OF GEORGIA.

         Section 9. Effect. Except as expressly herein amended, the terms and
conditions of the Credit Agreement shall remain in full force and effect.

         Section 10. Counterparts. This Amendment may be executed in multiple
counterparts, each of which shall be deemed to be an original and all of which,
taken together, shall constitute one and the same agreement. In proving this
Amendment in any judicial

                                      -3-
<PAGE>
proceedings, it shall not be necessary to produce or account for more than one
such counterpart signed by the party against whom such enforcement is sought.
Any signatures delivered by a party by facsimile transmission or by e-mail
transmission of an adobe file format document (also known as a PDF file) shall
be deemed an original signature hereto.

                         [Signatures on Following Page]

                                      -4-
<PAGE>
         IN WITNESS WHEREOF, the parties have caused this Fourth Amendment to
Credit Agreement to be executed by their authorized officers all as of the day
and year first above written.

                                        ROCK-TENN COMPANY

(CORPORATE SEAL)                        By: /s/ Gregory L. King
                                            -----------------------------------
                                            Title: Vice President

Attest:

By: /s/ Robert B McIntosh
   -----------------------------
   Title: Senior Vice President
          and General Counsel

                      [Signatures Continued on Next Page]

<PAGE>
            [Signature Page to Fourth Amendment to Credit Agreement]

                                        SUNTRUST BANK, AS AGENT, SWING LINE
                                        LENDER AND A LENDER

                                        By: /s/ Bradley S. Staples
                                            -----------------------------------
                                            Title: Managing Director

                                        WACHOVIA BANK, N.A., AS A LENDER AND
                                        DOCUMENTATION AGENT

                                        By: /s/ Shawn Janko
                                            -----------------------------------
                                            Title: Vice President

                                        BANK OF AMERICA, N.A., AS A LENDER AND
                                        SYNDICATION AGENT

                                        By: /s/ Thomas R Sullivan
                                            -----------------------------------
                                            Title: Vice President

                                        JPMORGAN CHASE BANK (FORMERLY KNOWN AS
                                        THE CHASE MANHATTAN BANK), AS A LENDER

                                        By: /s/ Peter S. Predun
                                            -----------------------------------
                                            Title: Vice President

                                        THE BANK OF TOKYO-MITSUBISHI, LTD., AS
                                        A LENDER

                                        By: /s/ Christian A. Giordano
                                            -----------------------------------
                                            Title: Authorized Signatory

                                        THE BANK OF NEW YORK,
                                        AS A LENDER

                                        By: /s/ David C. Siegel
                                            -----------------------------------
                                            Title: Vice President

                      [Signatures Continued on Next Page]

                                      -2-
<PAGE>
            [Signature Page to Fourth Amendment to Credit Agreement]

                                        FIRST UNION NATIONAL BANK,
                                        AS A LENDER

                                        By: /s/ Shawn Janko
                                            -----------------------------------
                                            Title: Vice President

                                        THE MIZUHO CORPORATE BANK, LTD.
                                        (FORMERLY KNOWN AS THE FUJI BANK,
                                        LIMITED), AS A LENDER

                                        By: /s/ Greg Botshon
                                            -----------------------------------
                                            Title: SVP and Team Leader

                                        BNP PARIBAS, AS A LENDER

                                        By:  /s/ John Stacy
                                            -----------------------------------
                                            Title: Managing Director

                                        By:  /s/ Mike Shryock
                                            -----------------------------------
                                            Title: Director

                                      -3-
<PAGE>
                                   EXHIBIT A

              ACKNOWLEDGMENT AND CONSENT OF SUBSIDIARY GUARANTORS

         Each of the undersigned Subsidiaries hereby (i) acknowledges receipt
of the foregoing Fourth Amendment to Credit Agreement by and among Rock-Tenn
Company, the Lenders under the Credit Agreement (the "LENDERS"), SunTrust Bank,
in its capacity as Agent for the Lenders (the "AGENT"), Bank of America, N.A.,
as Syndication Agent, and Wachovia Bank, N.A., as Documentation Agent (the
"AMENDMENT"), (ii) consents to the Amendment, (iii) agrees and acknowledges to
the terms thereof including, without limitation, the representations and
agreements of the each of the undersigned set forth in Section 6 of the
Amendment, and (iv) restates and affirms its respective obligations under its
Subsidiary Guarantee previously executed and delivered in favor of the Agent
(for the ratable benefit of the Lenders) without defense, counterclaim or
set-off.

         IN WITNESS WHEREOF, each of the undersigned Subsidiaries has executed
this Acknowledgment and Consent of Subsidiary Guarantors this 7th day of
December, 2004.

                                        ROCK-TENN COMPANY, MILL DIVISION, LLC.,
                                        a Tennessee limited liability company
                                        ROCK-TENN COMPANY OF TEXAS, a Georgia
                                        corporation
                                        ROCK-TENN COMPANY OF ILLINOIS, INC., an
                                        Illinois corporation
                                        ROCK-TENN CONVERTING COMPANY, a Georgia
                                        corporation
                                        WALDORF CORPORATION, a Delaware
                                        corporation
                                        WALDORF REALTY, INC., a Delaware
                                        corporation
                                        ROCK-TENN PARTITION COMPANY, a Georgia
                                        corporation
                                        PCPC, INC., a California corporation
                                        ROCK-TENN SHARED SERVICES, LLC, a
                                        Georgia limited liability company
                                        ROCK-TENN SERVICES INC., a Georgia
                                        corporation
                                        ROCK-TENN REAL ESTATE LLC, a Georgia
                                        limited liability company
                                        ROCK-TENN PACKAGING COMPANY, a Delaware
                                        corporation
                                        ROCK-TENN DISPLAY COMPANY, a Delaware
                                        corporation

                                        By: /s/ Gregory L. King
                                            -----------------------------------
                                            Name: Gregory L. King
                                            Title: Vice President

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