End-stage kidney disease is the complete or almost complete failure of the kidneys to work. The kidneys remove waste and excess water from the body.A.D.A.M.

Causes, incidence, and risk factors

End-stage kidney disease (ESRD) is when the kidneys are no longer able to work at a level needed for day-to-day life.

The most common causes of ESRD in the U.S. are diabetes and high blood pressure. These conditions can affect your kidneys.

ESRD almost always comes after chronic kidney disease. The kidneys may slowly stop working over 10 - 20 years before end-stage disease results.

Symptoms

Symptoms may include:

• General ill feeling and fatigue
• Itching (pruritus) and dry skin
• Headaches
• Weight loss without trying
• Loss of appetite
• Nausea

Other symptoms may include:

• Abnormally dark or light skin
• Nail changes
• Bone pain
• Drowsiness and confusion
• Problems concentrating or thinking
• Numbness in the hands, feet, or other areas
• Muscle twitching or cramps
• Breath odor
• Easy bruising, nosebleeds, or blood in the stool
• Excessive thirst
• Frequent hiccups
• Low level of sexual interest and impotence
• Menstrual periods stop (amenorrhea)
• Sleep problems, such as insomnia, restless leg syndrome, or obstructive sleep apnea
• Swelling of the feet and hands (edema)
• Vomiting, especially in the morning

Signs and tests

Your health care provider will perform a physical exam and order blood tests. Most people with this condition have high blood pressure.

Patients with end-stage kidney disease will make much less urine, or urine production may stop.

End-stage kidney disease changes the results of many tests. Patients receiving dialysis will need these and other tests done often:

• Potassium
• Sodium
• Albumin
• Phosphorous
• Calcium
• Cholesterol
• Magnesium
• Complete blood count (CBC)
• Electrolytes

This disease may also change the results of the following tests:

• Erythropoietin
• PTH
• Bone density test

Treatment

Dialysis or kidney transplantation is the only treatment for this condition.

For more information on these treatments, see:

• Dialysis
• Kidney transplant

Your doctor may also put you on medicine to control your blood pressure.

You may need to make changes in your diet.

• Eat a low-protein diet
• Get enough calories if you are losing weight
• Limit fluids
• Limit salt, potassium, phosphorous, and other electrolytes

For more information, see: Diet and chronic kidney disease

Other treatment depends on your symptoms but may include:

• Extra calcium and vitamin D (always talk to your doctor before taking)
• Medicines called phosphate binders, to help prevent phosphorous levels from becoming too high
• Treatment for anemia, such as extra iron in the diet, iron pills or shots, shots of a medicine called erythropoietin, and blood transfusions.

You should be up-to-date on important vaccinations, including:

• H1N1 (swine flu) vaccine
• Hepatitis A vaccine
• Hepatitis B vaccine
• Influenza vaccine
• Pneumococcal polysaccharide vaccine (PPV)

Support Groups

See: Kidney disease support group

Expectations (prognosis)

End-stage kidney disease leads to death if you do not have dialysis or a kidney transplant. However, both of these treatments can have risks. The outcome is different for each person.

Complications

• Anemia
• Bleeding from the stomach or intestines
• Bone, joint, and muscle pain
• Brain dysfunction, confusion, and dementia
• Changes in electrolyte levels
• Changes in blood sugar (glucose)
• Damage to nerves of the legs and arms
• Fluid buildup around the lungs
• Heart and blood vessel complications

  • Congestive heart failure
  • Coronary artery disease
  • High blood pressure
  • Pericarditis
  • Stroke
• Hepatitis B, hepatitis C, liver failure
• Hyperparathyroidism
• Increased risk of infections
• Malnutrition
• Phosphorous levels become too high
• Potassium levels become too high
• Seizures
• Skin dryness, itching/scratching, leading to skin infection
• Weakening of the bones, fractures, joint disorders

Prevention

Treatment of chronic kidney disease may delay or prevent progression to ESRD. Some cases may not be preventable.

References

1. Himmelfarb J, Ikizler TA. Hemodialysis. N Engl J Med. 2010 Nov 4;363(19):1833-45. Review. PubMed PMID: 21047227. [PubMed: 21047227]
2. Tonelli M, Pannu N, Manns B. Oral phosphate binders in patients with kidney failure. N Engl J Med. 2010 Apr 8;362(14):1312-24. [PubMed: 20375408]
3. Abboud H, Henrich WL. Clinical practice. Stage IV chronic kidney disease. NEngl J Med. 2010 Jan 7;362(1):56-65. [PubMed: 20054047]
4. KDOQI. KDOQI Clinical Practice Guideline and Clinical Practice Recommendations for anemia in chronic kidney disease: 2007 update of hemoglobin target. Am J Kidney Dis. 2007;50:471-530. [PubMed: 17720528]
5. KDOQI: National Kidney Foundation. II. Clinical practice guidelines and clinical practice recommendations for anemia in chronic kidney disease in adults. Am J Kidney Dis. 2006;47(5 Suppl 3):S16-S85. [PubMed: 16678661]
6. Palmer SC, Navaneethan SD, Craig JC, Johnson DW, Tonelli M, Garg AX, et al. Meta-analysis: erythropoiesis-stimulating agents in patients with chronic kidney disease. Ann Intern Med. 2010;153:23-33. [PubMed: 20439566]

Review Date: 9/21/2011.

Reviewed by: David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc., andHerbert Y. Lin, MD, PHD, Nephrologist, Massachusetts General Hospital; Associate Professor of Medicine, Harvard Medical School.