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End-stage kidney disease

Definition

End-stage kidney disease is the complete, or almost complete failure of the kidneys to function. The main function of the kidneys is to remove wastes and excess water from the body.

Alternative Names

Renal failure - end stage; Kidney failure - end stage; ESRD

Causes, incidence, and risk factors

End-stage kidney disease (ESRD) occurs when the kidneys are no longer able to function at a level needed for day-to-day life. It usually occurs when chronic kidney disease has worsened to the point at which kidney function is less than 10% of normal.

ESRD almost always follows chronic kidney disease. A person may have gradual worsening of kidney function for 10 - 20 years or more before progressing to ESRD.

Patients who have reached this stage need dialysis or a kidney transplant.

The most common causes of ESRD in the U.S. are diabetes and high blood pressure. See Chronic kidney disease for a complete list of causes.

Symptoms

Symptoms may include:

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

Other symptoms may develop, including:

• Abnormally dark or light skin and changes in nails
• Bone pain
• Brain and nervous system symptoms
  • 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

High blood pressure almost always occurs during end-stage kidney disease. A brain and nervous system (neurologic) examination may show signs of nerve damage. The health care provider may hear abnormal heart or lung sounds with a stethoscope.

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 ESRD.

You should begin to prepare for dialysis before it is absolutely necessary. The preparation includes learning about dialysis and the types of dialysis therapies, and placement of a dialysis access.

See also:

• Dialysis
• Kidney transplant

Treatment usually includes an ACE inhibitor, angiotensin receptor blocker, or other medications for high 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

See Diet and chronic kidney disease for more detail.

Other treatments may include:

• Extra calcium and vitamin D (always talk to your doctor before taking)
• Special 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, special shots of a medicine called erythropoietin, and blood transfusions.

Different treatments are available for problems with sleep or restless leg syndrome.

Patients with chronic kidney disease 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

For additional resources, see kidney disease support group.

Expectations (prognosis)

Without dialysis or a kidney transplant, death will occur from the buildup of fluids and waste products in the body. Both of these treatments can have serious risks and consequences. 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

Tolkoff-Rubin N. Treatment of irreversible renal failure. In: Goldman L, Ausiello D, eds. Goldman: Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 133.

Mitch WE. Chronic kidney disease. In: Goldman L, Ausiello D, eds. Goldman: Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 131.

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.

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.

Kidney Disease Outcomes Quality Initiative (K/DOQI). K/DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease. Am J Kidney Dis. 2004;43(5 Suppl 1):S1-S290.

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.