Kidney failure - end stage

Alternative names
Renal failure - end stage; End-stage kidney disease; ESRD

End-stage kidney disease is a complete or near complete failure of the kidneys to function to excrete wastes, concentrate urine, and regulate electrolytes. Also called End-stage renal disease (ESRD).

Causes, incidence, and risk factors
End-stage kidney disease occurs when the kidneys are no longer able to function at a level that is necessary for day to day life. It usually occurs as chronic renal failure progresses to the point where kidney function is less than 10% of baseline. At this point, the kidney function is so low that without dialysis or kidney transplantation, complications are multiple and severe, and death will occur from accumulation of fluids and waste products in the body.

In the United States, nearly 300,000 people are on long-term dialysis and more than 20,000 have a functioning transplanted kidney. The most common cause of ESRD in the US is diabetes. ESRD almost always follows chronic kidney failure, which may exist for 10 to 20 years or more before progression to ESRD.


  • Unintentional weight loss  
  • Nausea or vomiting  
  • General ill feeling  
  • Fatigue  
  • Headache  
  • Frequent hiccups  
  • Generalized itching  
  • Greatly decreased urine output  
  • No urine output  
  • Easy bruising or bleeding  
  • May have blood in the vomit or stools  
  • Decreased alertness       o drowsiness, somnolence, lethargy       o confusion, delirium       o coma  
  • Muscle twitching or cramps  
  • Seizures  
  • Increased skin pigmentation  
  • Skin may appear yellow or brown  
  • Nail abnormalities  
  • Decreased sensation in the hands, feet, or other areas

Signs and tests
The patient usually has a long history of chronic kidney failure, which has progressed. The person may have required dialysis to control chronic renal failure. The urine volume may decrease or urine production may stop totally. Signs of complications commonly are present.

  • Creatinine and BUN levels are chronically high.  
  • Creatinine clearance is very low.


Dialysis or kidney transplantation are the only treatments for ESRD. The physical condition of the person and other factors determines which of these is used for treatment. Other treatments of chronic kidney failure may continue but are ineffective without dialysis or transplantation.

Associated diseases that cause or result from chronic renal failure must be controlled. Hypertension, congestive heart failure, urinary tract infections, kidney stones, obstructions of the urinary tract, glomerulonephritis, and other disorders should be treated as appropriate.

Blood transfusions and medications such as iron and erythropoietin may be needed to control anemia. Fluids may be restricted to an amount nearly equal to the volume of urine produced.

Dietary restrictions may slow the build-up of wastes in the bloodstream and control associated symptoms such as nausea and vomiting. Restrictions include low protein in diet, with high carbohydrate levels to make up calories. Salt, potassium, phosphorus, and other electrolytes may be restricted.

Support Groups
For additional resources, see kidney disease support group.

Expectations (prognosis)
ESRD is fatal unless treated with dialysis or transplantation. Both of these treatments can have serious risks and consequences. The outcome varies and is unique to each individual.


  • Pericarditis, Cardiac tamponade  
  • Congestive heart failure  
  • Hypertension  
  • Platelet dysfunction  
  • Gastrointestinal loss of blood; duodenal or peptic ulcers  
  • Hemorrhage  
  • Anemia  
  • Hepatitis B, hepatitis C, liver failure  
  • Decreased functioning of white blood cells and immune system  
  • Infection  
  • Peripheral neuropathy  
  • Seizures  
  • Encephalopathy, nervous system damage, dementia  
  • Weakening of the bones, fractures, joint disorders  
  • Permanent skin pigmentation changes  
  • Skin dryness, itching/scratching with resultant skin infection  
  • Changes in glucose metabolism  
  • Changes in electrolyte levels  
  • Decreased libido, impotence  
  • Miscarriage, menstrual irregularities, infertility

Calling your health care provider
Go to the emergency room or call the local emergency number (such as 911) if symptoms indicating end-stage kidney disease have developed. Call your health care provider if known acute or chronic kidney failure persists or worsens.

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

Johns Hopkins patient information

Last revised: December 7, 2012
by Sharon M. Smith, M.D.

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