End Stage Renal Disease

End stage renal disease is a serious condition where your kidneys no longer work well enough to keep you alive without medical help. When this happens, dangerous levels of waste products and fluids build up in your body, requiring dialysis or a kidney transplant to survive.

Table of contents

• What is end stage renal disease?
• Common causes
• Signs and symptoms
• How is it diagnosed?
• Stages of kidney disease
• Treatment options
• Living with end stage renal disease
• Medicare coverage

End-stage kidney disease, kidney failure, ESRD

What is end stage renal disease?

End stage renal disease occurs when chronic kidney disease (the gradual loss of kidney function) reaches an advanced state. At this point, your kidneys no longer work as they should to meet your body’s needs.^[1]

Your kidneys normally filter wastes and excess fluids from your blood, which are then removed in your urine. When your kidneys lose their filtering abilities, dangerous levels of fluid, chemicals called electrolytes, and wastes can build up in your body.^[1]

End stage renal disease is defined by a glomerular filtration rate (GFR) of less than 15 mL/min/1.73 m². The GFR is a measure of how well your kidneys filter blood. This advanced stage often requires renal replacement therapy such as dialysis or kidney transplantation.^[2]

More than 500,000 people in the United States live with end stage renal disease. The development of chronic kidney disease and its progression to this final stage remains a significant cause of reduced quality of life and early death.^[2]

Common causes

End stage renal disease results from progressive loss of kidney function and is most commonly caused by diabetes, high blood pressure, and diseases affecting the kidney’s filtering units.^[2]

Diabetes mellitus is the leading cause of end stage renal disease. Kidney disease can result from either type 1 or type 2 diabetes. With either type, poor control of blood sugar increases the risk of reaching this advanced stage.^[18]

Other common causes include high blood pressure, hardening of the arteries, autoimmune diseases like systemic lupus erythematosus (lupus), genetic disorders such as polycystic kidney disease, and exposure to certain medications including some antibiotics, chemotherapy drugs, and pain relievers.^[18]

Signs and symptoms

Early in chronic kidney disease, you might have no signs or symptoms. As the disease progresses to end stage renal disease, signs and symptoms might include:^[1]

• Nausea and vomiting
• Loss of appetite
• Fatigue and weakness
• Changes in how much you urinate
• Chest pain, if fluid builds up around the lining of the heart
• Shortness of breath, if fluid builds up in the lungs
• Swelling of feet and ankles

Additional symptoms may include weight loss, feeling generally unwell, headaches, hiccups, itching, easy bruising or bleeding, decreased alertness, difficulty breathing, and seizures.^[18]

Symptoms may remain mild or absent until kidney function drops to less than 20% of normal.^[18]

How is it diagnosed?

To diagnose end stage renal disease, your health care provider may ask you about your family’s and your medical history. You may also have physical and neurological exams, along with other tests.^[7]

Kidney disease is diagnosed through urine and blood tests. These tests measure levels of waste products such as creatinine and urea nitrogen in the urine and blood.^[18]

Common diagnostic tests include:^[7]

• Blood tests to measure the amount of waste products like creatinine and urea in your blood
• Urine tests to check the level of the protein albumin in your urine
• Imaging tests such as ultrasound, MRI, or CT scan to assess your kidneys and look for unusual areas
• Removing a sample of kidney tissue (biopsy) to examine under a microscope to learn what type of kidney disease you have and how much damage there is

Additional tests may be necessary to determine why the kidneys have stopped working. Certain tests might be repeated over time to help your provider follow the progress of your kidney disease.^[7]

Stages of kidney disease

There are five stages of kidney disease. To determine what stage you have, your health care provider performs a blood test to check your glomerular filtration rate (GFR). The GFR measures how much blood the kidneys filter each minute, recorded as milliliters per minute (mL/min).^[7]

As the GFR declines, so does your kidney function. When your kidneys no longer work at a level that’s necessary to keep you alive, you have end stage renal disease. End stage renal disease usually occurs when kidney function is less than 15% of typical kidney function.^[7]

By definition, chronic kidney disease is present when both factors are present: GFR less than 60 mL/min and albumin greater than 30 mg in the urine.^[2]

As a part of kidney disease staging, your provider also might test whether you have protein in your urine. The Kidney Disease: Improving Global Outcomes guidelines provide a framework for staging chronic kidney disease and guiding management based on GFR and albuminuria levels.^[2]

Treatment options

With end stage renal disease, you need dialysis or a kidney transplant to stay alive. You can also choose to opt for conservative care to manage your symptoms, aiming for the best quality of life during your remaining time.^[1]

Kidney transplantation typically yields the best patient outcomes, although most patients are treated with dialysis. The decision to initiate dialysis is best made through shared decision-making between you, your family, and your physicians.^[9]

Dialysis is a treatment that helps filter waste from your blood when your kidneys can no longer do this job. There are two main types: hemodialysis and peritoneal dialysis.^[3]

If you’re on dialysis, Medicare coverage usually starts on the first day of the fourth month of your dialysis treatments. This 4-month waiting period will start even if you haven’t signed up for Medicare. Medicare coverage can begin as early as the first month of dialysis treatments if you participate in a home dialysis training program during the first 3 months of your regular course of dialysis.^[3]

If you’re getting a kidney transplant, Medicare coverage can begin the month you’re admitted to a Medicare-certified hospital for a kidney transplant (or for health care services that you need before your transplant) if your transplant takes place in that same month or within the next 2 months.^[3]

A palliative approach to end stage renal disease is a reasonable alternative to dialysis, particularly for individuals with limited life expectancy, with severe other medical conditions, or who wish to avoid medical interventions.^[9]

Living with end stage renal disease

Many people with chronic kidney disease are able to live long lives without being unduly affected by the condition. Although it’s not possible to repair damage that has already happened to your kidneys, the disease will not necessarily get worse. Chronic kidney disease only reaches an advanced stage in a small proportion of people.^[19]

Taking an active role in managing chronic kidney disease will help you feel better and improve your overall well-being. Even if your condition is mild, it’s important to take good care of yourself to help stop it getting worse and reduce your risk of other health problems, such as heart disease and stroke.^[16]

Because most patients with end stage renal disease elect to receive hemodialysis, the preservation of peripheral veins is important for those with stage III to V chronic kidney disease. Avoid excessive blood draws, certain types of intravenous catheters, and specific vein access procedures unless necessary.^[9]

For patients with end stage renal disease, vaccination against seasonal influenza, tetanus, hepatitis B, human papillomavirus (through 26 years of age), and Streptococcus pneumoniae is advised.^[9]

Important self-care measures include:^[19]

• Take your medicines exactly as prescribed, even if you feel well
• Be physically active. Physical activity can boost your energy, help you sleep, strengthen your bones, and help prevent depression
• Eat a healthy, balanced diet. You may need to work with a dietitian to create an eating plan with the right amounts of salt (sodium), potassium, and protein
• Quit smoking if you smoke
• Limit how much alcohol you drink

If you have diabetes and chronic kidney disease, finding the best foods to eat can be challenging. Some foods that work for both diabetes and chronic kidney disease include fruits like berries, grapes, cherries, apples, and plums; vegetables such as cauliflower, onions, eggplant, and turnips; lean meats, poultry, fish, eggs, and unsalted seafood; and white bread, bagels, and pasta.^[16]

Controlling blood pressure in patients receiving dialysis improves survival. Volume control through adequate dialysis and sodium restriction can help optimize hypertension treatment in these patients. Insulin is the preferred treatment for patients with end stage renal disease and diabetes requiring medication.^[9]

Patients with end stage renal disease experience significant illness, reduced quality of life, and increased risk of death. Despite available guidelines, many patients initiate dialysis without prior kidney specialist referral, permanent access placement, or education about treatment options, which contributes to poor short-term outcomes and missed opportunities for timely intervention.^[2]

Medicare coverage

End stage renal disease is when you have permanent kidney failure that requires a regular course of dialysis or a kidney transplant.^[3]

If you have end stage renal disease, you can get Medicare no matter how old you are if all of these apply:^[3]

• Your kidneys no longer work
• You need regular dialysis or have had a kidney transplant
• You’ve worked the required amount of time under Social Security, the Railroad Retirement Board, or as a government employee; or you’re already getting or are eligible for Social Security or Railroad Retirement benefits; or you’re the spouse or dependent child of a person who meets these requirements

If you’re eligible for Medicare because of end stage renal disease and you qualify for Part A, you can also get Part B. Signing up for Medicare is your choice, but you’ll need both Part A and Part B to get the full benefits available under Medicare to cover certain dialysis and kidney transplant services.^[3]

You can sign up for Part A and Part B by contacting your local Social Security office or by calling Social Security. If you apply for Medicare and you’re approved because of end stage renal disease, you can sign up for Part B without paying a late enrollment penalty.^[3]

• Kidneys
• Blood