EXHIBIT 10.19
 
                       AMENDMENT NO. 1 AND CONSENT NO. 1
                                       TO
                AMENDED AND RESTATED REVOLVING CREDIT AGREEMENT
 
  AMENDMENT NO. 1 AND CONSENT NO. 1 (this "Amendment"), dated as of August 5,
1998, to the Amended and Restated Revolving Credit Agreement (the "Revolving
Credit Agreement"), dated as of April 30, 1998, by and among TOTAL RENAL CARE
HOLDINGS, INC., a Delaware corporation (the "Borrower"), the lenders party
thereto (the "Lenders"), DLJ CAPITAL FUNDING, INC., as Syndication Agent (the
"Syndication Agent"), FIRST UNION NATIONAL BANK, as Documentation Agent, and
THE BANK OF NEW YORK, as administrative agent (in such capacity, the
"Administrative Agent").
 
                                    RECITALS
 
  I. Capitalized terms used herein which are not otherwise defined herein shall
have the respective meanings ascribed thereto in the Revolving Credit
Agreement.
 
  II. The Borrower has requested that the Administrative Agent and the Lenders
agree to amend the Revolving Credit Agreement upon the terms and conditions
contained herein, and the Administrative Agent and the Required Lenders are
willing to so agree.
 
  Accordingly, in consideration of the Recitals and the covenants and
conditions hereinafter set forth, and for other good and valuable
consideration, the receipt and adequacy of which are hereby acknowledged, the
parties hereto hereby agree as follows:
 
  1. Section 4.19 of the Revolving Credit Agreement is amended and restated in
its entirety to read as follows:
 
  The facilities operated by the Borrower and its Subsidiaries (the
  "Facilities") are qualified for participation in the Medicare and Medicaid
  programs (together with their respective intermediaries or carriers, the
  "Government Reimbursement Programs") and are entitled to reimbursement
  under the Medicare program for services rendered to qualified Medicare
  beneficiaries, and comply in all material respects with the conditions of
  participation in all Government Reimbursement Programs. There is no pending
  or, to Borrower's knowledge, threatened proceeding or investigation by any
  of the Government Reimbursement Programs with respect to (i) the Borrower's
  or any of its Subsidiaries' qualification or right to participate in any
  Government Reimbursement Program, (ii) the compliance or non-compliance by
  the Borrower or any of its Subsidiaries with the terms or provisions of any
  Government Reimbursement Program, or (iii) the right of the Borrower or any
  of its Subsidiaries to receive or retain amounts received or due or to
  become due from any Government Reimbursement Program, which proceeding or
  investigation, together with all other such proceedings and investigations,
  could reasonably be expected to have a Material Adverse Effect.
 
  2. Section 9.1(p) of the Revolving Credit Agreement is amended and restated
in its entirety to read as follows:
 
    (p) The Borrower or any Subsidiary, in each case to the extent it is
  engaged in the business of providing services for which Medicare or
  Medicaid reimbursement is sought, shall for any reason, including, without
  limitation, as the result of any finding, designation or decertification,
  lose its right or authorization, or otherwise fail to be eligible, to
  participate in Medicaid or Medicare programs or to accept assignments or
  rights to reimbursements under Medicaid regulations or Medicare
  regulations, or the Borrower or any Subsidiary has, for any reason, had its
  right to receive reimbursements under Medicaid or Medicare regulations
  suspended, and such loss, failure or suspension (together with all such
  other losses, failures and suspensions continuing at such time) shall have
  resulted in a Material Adverse Effect.

 
  3. The Administrative Agent and the Lenders, to the extent their consent is
required, hereby consent to the amendment of the Term Loan Facility in a manner
substantially similar to this Amendment (the "First Term Loan Amendment").
 
  4. Paragraphs 1 through 3 of this Amendment shall become and shall be deemed
effective as of April 30, 1998 upon the prior or simultaneous satisfaction of
the following condition:
 
    (a) The First Term Loan Amendment shall have become effective, and the
  Administrative Agent shall have received a copy of the executed First Term
  Loan Amendment.
 
  5. On the date hereof, each Credit Party hereby (a) reaffirms and admits the
validity and enforceability of the Loan Documents (as amended by this
Amendment) and all of its obligations thereunder, (b) agrees and admits that it
has no defenses to or offsets against any such obligation, and (c) represents
and warrants that, after giving effect to the effectiveness of this Amendment,
no Default or Event of Default has occurred and is continuing, and that each of
the representations and warranties made by it in the Loan Documents (as amended
by this Amendment) to which it is a party is true and correct with the same
effect as though such representation and warranty had been made on the date
hereof.
 
  6. In all other respects, the Loan Documents shall remain in full force and
effect, and no amendment in respect of any term or condition of any Loan
Document contained herein shall be deemed to be an amendment in respect of any
other term or condition contained in any Loan Document.
 
  7. This Amendment may be executed in any number of counterparts all of which,
taken together, shall constitute one Amendment. In making proof of this
Amendment, it shall only be necessary to produce the counterpart executed and
delivered by the party to be charged.
 
  8. THIS AMENDMENT IS BEING EXECUTED AND DELIVERED IN, AND IS INTENDED TO BE
PERFORMED IN, THE STATE OF NEW YORK AND SHALL BE CONSTRUED AND ENFORCEABLE IN
ACCORDANCE WITH, AND BE GOVERNED BY, THE INTERNAL LAWS OF THE STATE OF NEW
YORK, WITHOUT REGARD TO PRINCIPLES OF CONFLICT OF LAWS.

 
                       AMENDMENT NO. 1 AND CONSENT NO. 1
                                       TO
                AMENDED AND RESTATED REVOLVING CREDIT AGREEMENT
 
  AS EVIDENCE of the agreement by the parties hereto to the terms and
conditions herein contained, each such party has caused this Amendment to be
executed on its behalf.
 
                                          TOTAL RENAL CARE HOLDINGS, INC.
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title:  _____________________________
 
                                          THE BANK OF NEW YORK,
                                          Individually, as the Letter of
                                           Credit Issuer, as the Swing Line
                                           Lender and as Administrative Agent
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          DLJ CAPITAL FUNDING, INC.,
                                          Individually and as Syndication
                                           Agent
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          FIRST UNION NATIONAL BANK,
                                          Individually and as Documentation
                                           Agent
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          ABN AMRO BANK N.V.
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________

 
                       AMENDMENT NO. 1 AND CONSENT NO. 1
                                       TO
                AMENDED AND RESTATED REVOLVING CREDIT AGREEMENT
 
                                          ALLIED IRISH BANKS, P.L.C.,
                                          CAYMAN ISLANDS BRANCH
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          BANCO ESPIRITO SANTO E COMERCIAL DE
                                          LISBOA, NASSAU BRANCH
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          BANK LEUMI TRUST COMPANY OF NEW YORK
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          By: _________________________________
                                          Name: _______________________________
                                          Title: ______________________________
 
                                          THE BANK OF NOVA SCOTIA
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________

 
                       AMENDMENT NO. 1 AND CONSENT NO. 1
                                       TO
                AMENDED AND RESTATED REVOLVING CREDIT AGREEMENT
 
                                          BANQUE NATIONALE DE PARIS
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          BHF-BANK AKTIENGESELLSCHAFT
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          CITY NATIONAL BANK
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          CREDITANSTALT CORPORATE FINANCE,
                                          INC.
 
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________

 
                       AMENDMENT NO. 1 AND CONSENT NO. 1
                                       TO
                AMENDED AND RESTATED REVOLVING CREDIT AGREEMENT
 
                                          CREDIT LYONNAIS NEW YORK BRANCH
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          DEUTSCHE BANK AG, NEW YORK AND/OR
                                           CAYMAN ISLANDS BRANCHES
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          DRESDNER BANK AG, NEW YORK BRANCH
                                          AND GRAND CAYMAN BRANCH
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          FLEET NATIONAL BANK
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          THE FUJI BANK, LIMITED
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________

 
                       AMENDMENT NO. 1 AND CONSENT NO. 1
                                       TO
                AMENDED AND RESTATED REVOLVING CREDIT AGREEMENT
 
                                          HIBERNIA NATIONAL BANK
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          THE INDUSTRIAL BANK OF JAPAN, LTD.,
                                          LOS ANGELES AGENCY
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          KBC BANK
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title _______________________________
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          LONG TERM CREDIT BANK OF JAPAN, LTD.
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          MELLON BANK, N.A.
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          MICHIGAN NATIONAL BANK
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________

 
                       AMENDMENT NO. 1 AND CONSENT NO. 1
                                       TO
                AMENDED AND RESTATED REVOLVING CREDIT AGREEMENT
 
                                          THE MITSUBISHI TRUST AND BANKING
                                          CORPORATION
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          NATIONAL CITY BANK OF KENTUCKY
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          PARIBAS
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title _______________________________
 
                                          COOPERATIEVE CENTRALE
                                          RAIFFEISEN--BOERENLEENBANK B.A,
                                          "RABOBANK NEDERLAND", NEW YORK
                                          BRANCH
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          ROYAL BANK OF CANADA
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________

 
                       AMENDMENT NO. 1 AND CONSENT NO. 1
                                       TO
                AMENDED AND RESTATED REVOLVING CREDIT AGREEMENT
 
                                          THE ROYAL BANK OF SCOTLAND PLC
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          THE SANWA BANK, LIMITED
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          SOCIETE GENERALE
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          THE SUMITOMO TRUST & BANKING CO.,
                                          LTD., NEW YORK BRANCH
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          SUNTRUST BANK, NASHVILLE, N.A.
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          THE TOKAI BANK, LIMITED
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________

 
                       AMENDMENT NO. 1 AND CONSENT NO. 1
                                       TO
                AMENDED AND RESTATED REVOLVING CREDIT AGREEMENT
 
                                          THE TOYO TRUST & BANKING CO., LTD.,
                                          Los Angeles Agency
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          UNION BANK OF CALIFORNIA, N.A.
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________
 
                                          U.S. BANK NATIONAL ASSOCIATION
 
                                          By: _________________________________
 
                                          Name: _______________________________
 
                                          Title: ______________________________

 
                       AMENDMENT NO. 1 AND CONSENT NO. 1
                                       TO
                AMENDED AND RESTATED REVOLVING CREDIT AGREEMENT
 
AGREED AND CONSENTED TO:
 
TOTAL RENAL CARE, INC.
 
By: ______________________________________
 
Name: ____________________________________
 
Title: ___________________________________
 
TRC WEST, INC.
 
By: ______________________________________
 
Name: ____________________________________
 
Title: ___________________________________
 
TOTAL RENAL CARE ACQUISITION CORP.
 
By: ______________________________________
 
Name: ____________________________________
 
Title: ___________________________________
 
RENAL TREATMENT CENTERS, INC.
 
By: ______________________________________
 
Name: ____________________________________
 
Title: ___________________________________
 
RENAL TREATMENT CENTERS--MID-ATLANTIC, INC.
 
By: ______________________________________
 
Name: ____________________________________
 
Title: ___________________________________
 
RENAL TREATMENT CENTERS--NORTHEAST, INC.
 
By: ______________________________________
 
Name: ____________________________________
 
Title: ___________________________________

 
                       AMENDMENT NO. 1 AND CONSENT NO. 1
                                       TO
                AMENDED AND RESTATED REVOLVING CREDIT AGREEMENT
 
RENAL TREATMENT CENTERS--CALIFORNIA, INC.
 
By: ______________________________________
 
Name: ____________________________________
 
Title: ___________________________________
 
RENAL TREATMENT CENTERS--WEST, INC.
 
By: ______________________________________
 
Name: ____________________________________
 
Title: ___________________________________
 
RENAL TREATMENT CENTERS--SOUTHEAST, INC.
 
By: ______________________________________
 
Name: ____________________________________
 
Title: ___________________________________