End-stage renal disease (ESRD) is kidney failure that requires dialysis or a kidney transplant if a patient is to continue living. As a result of ESRD, kidney function is stopped or severely impaired. Without working kidneys, fluids and waste products remain in the body. Their accumulation can lead to severe symptoms, as well as contribute to cardiovascular disease and other health conditions. ESRD is eventually fatal without treatment.

Healthy kidneys filter waste products, toxins and excess water from the blood. When the kidneys fail, these materials remain in the blood and proteins leak into the urine. Because of the protein loss and limited filtration, patients with ESRD are likely to experience edema (swelling), high blood pressure, reduced production of red blood cells and a buildup of wastes in the blood.

Diabetes is the leading risk factor for ESRD, and high blood pressure is second. Nearly half of all patients with ESRD also have diabetes, according to the American Diabetes Association (ADA). When diabetes and high blood pressure are combined, they account for about 60 percent of all cases of ESRD, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Other potential causes of ESRD include other chronic kidney diseases, heart failure and lupus (an autoimmune disease).

Diagnosis of ESRD is made with a combination of blood tests and urine tests. The presence of proteins in the urine is one of the strongest indicators of kidney damage. The diagnosis is confirmed through an indirect measure of the patient’s glomerular filtration rate.

Dialysis, the most common treatment for ESRD, replaces the impaired filtering ability of the kidneys. Eventually, most patients with ESRD will require a kidney transplant. The transplant gives the ESRD patient a healthy, functioning kidney from a cadaver or living donor. The new kidney cures ESRD and is likely to last between five and 15 years.

Kidney disease must be detected early to prevent progression to ESRD. Regular checkups can detect the presence of protein in the urine, an early indicator of kidney damage. Checkups are recommended at scheduled intervals for patients with diabetes, high blood pressure and other risk factors for kidney disease. Prevention can also be accomplished by controlling blood sugar (glucose), blood pressure and cholesterol levels. Additional preventive steps may involve limiting dietary salt, protein and alcohol intake.

End-stage renal disease (ESRD) is the total or near-total loss of kidney function. By the time ESRD develops, the kidneys may be operating at less than 10 percent of their healthy capability. To live, the patient will require either dialysis or a kidney transplant.

The kidneys are fist-sized, bean-shaped structures located in the middle of the back on both sides of the spine. About 200 quarts of blood pass through them every day, from which the kidneys remove about 2 quarts of waste products and excess water in the form of urine. By removing excess water from the blood, the kidneys help keep blood pressure from rising too high, prevent the heart from becoming overloaded and allow chemicals in the blood to remain undiluted and in balance. The kidneys also release hormones that help the body create red blood cells, regulate blood pressure and maintain proper calcium levels in the body.

Each kidney is composed of roughly 1 million filtering units called nephrons. The nephrons are made up of tiny blood vessels called glomeruli. During kidney failure, the glomeruli lose their filtering capability and proteins may leak into the urine. When the kidneys begin to fail, they are no longer able to excrete wastes, concentrate urine or regulate electrolyte levels in the body.

Chronic kidney disease progresses through five generally recognized stages. Stages one through three are characterized by increasing levels of damage to the kidneys. However, they do not typically produce noticeable symptoms. Kidney filtration is substantially impaired by stage four, and waste products collecting in the blood may cause increasingly severe symptoms. Stage five is ESRD and generally the kidneys are unable to regulate the body’s balance of salt and water. Production of urine slows or stops. Waste products and water accumulate in the body, leading to a potentially life-threatening overload of these substances.

More than 450,000 Americans were undergoing treatment for ESRD in 2003, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) reported in 2007. United States rates of kidney failure have stabilized since 1999, after a two-decade surge in which rates increased 5 to 10 percent a year, according to the NIDDK.

End-stage renal disease (ESRD) is caused by kidney disease that progressively becomes more severe. Chronic kidney disease, kidney failure and ESRD occur across a continuum of increasingly more severe symptoms. As the kidney disease advances, typically over years or decades, the ability of the kidneys to remove waste products from the blood is significantly reduced and toxins collect in the body. Kidney failure is when filtration is so limited that it contributes to systemic conditions, such as bone disease, anemia (reduced red blood cell or hemoglobin levels) and acidosis (increased acidity of the body tissues). With the occurrence of ESRD, filtration is reduced so much that the patient requires treatment with dialysis or a kidney transplant to live.

Diabetes is one of the most common causes of kidney damage (diabetic nephropathy) and is a major risk factor for ESRD. High glucose (blood sugar) levels act as a poison to the kidneys, damaging them. Nearly half of all new cases of chronic kidney failure are due to diabetes, according to the National Institutes of Health (NIH). Patients with type 1 diabetes may progress to ESRD within five to 10 years if they chronically have protein in their urine (proteinuria). Type 1 patients are 12 times more likely to develop ESRD than those with type 2, according to the American Diabetes Association. However, type 2 diabetes is far more common and causes more total cases of ESRD.

The kidneys and cardiovascular system are highly dependent on each other. High blood pressure (hypertension) is the second most common cause of chronic kidney failure that progresses to ESRD. Without treatment, high blood pressure can damage blood vessels in the kidneys, making them unable to properly filter waste products from the blood.

However, kidney disease can also cause high blood pressure. Kidney failure and heart failure may occur together. Heart failure causes constriction of the blood vessels, reduced cardiac output and low blood pressure (hypotension) that prevents the kidneys from functioning properly and can cause kidney failure. However, whenever kidney failure occurs, toxins that collect in the blood may poison the heart tissue and cause it to fail.

Other possible causes of kidney disease that may lead to ESRD include:

• Glomerulonephritis. Swelling and scarring of the glomeruli of the kidneys.
  
  
• Vasculitis. Inflammation of the blood vessels.
  
  
• Interstitial nephritis. Inflammation of the interior spaces of the kidneys.
  
  
• Toxins. This may include prescription or over-the-counter medications (e.g., aspirin, acetaminophen, ibuprofen) taken for prolonged periods of time.
  
  
• Physical trauma to the kidneys.
  
  
• Polycystic kidney disease. Tendency to develop cysts in kidney tissue that enlarge the size of the organ and disrupt kidney function.
  
  
• Kidney stones. Solid masses that form in the kidneys. Research has found that risk factors for kidney stones include type 2 diabetes and obesity.
  
  
• Congenital nephritic syndrome. Inherited kidney disorder that occurs in infancy.

Other, less common causes of kidney disease that can lead to ESRD include:

• Systemic lupus erythematosus. An autoimmune disease that causes joint, skin and organ swelling.
  
  
• Interstitial cystitis. Inflammation and swelling of the bladder wall.
  
  
• Obstructive uropathy. Blockage in the urinary tract. Causes can include severe cases of prostate enlargement (benign prostatic hyperplasia).
  
  
• Multiple myeloma. A form of bone marrow cancer.
  
  
• Vesicoureteral reflux. Backwashing in the urinary bladder and ureters (the tubes that connect the kidneys to the bladder) occurring in children and young adults.

Other factors place certain populations at greater risk for developing ESRD. Most patients are in their 60s when ESRD develops. However, it can occur at any age and in 1997 a quarter of new ESRD patients were younger than age 45, according to the NIH. The NIH also indicates that ESRD occurs at higher rates among African-Americans, American Indians and Alaska Natives than whites and Asian Americans when other risk factors are also present.

Symptoms of kidney failure do not typically begin to appear until serious health problems have developed.

Patients with kidney disease are likely to experience water retention, high blood pressure, reduced production of red blood cells and buildup of waste products in the blood. Accumulation of wastes in the body can lead to nausea, vomiting and edema (swelling from fluid retention).

Chronic kidney disease may progress for years or even decades before end-stage renal disease (ESRD) develops. Signs and symptoms of ESRD may include:

• Anemia (reduced number of red blood cells, hemoglobin or blood volume)
  
  
• High blood pressure
  
  
• Heart failure
  
  
• Bone disease
  
  
• Gastrointestinal problems
  
  
• Dementia
  
  
• Significant decrease or stop in urine production

Additional symptoms are likely to occur that are common in kidney disease, but not specific to ESRD. Some examples include:

• Increased susceptibility to infections
  
  
• Itching skin (pruritus)
  
  
• Easy bruising
  
  
• Blood in vomit or stools
  
  
• Metallic taste in the mouth
  
  
• Mental slowness, confusion
  
  
• Hiccups
  
  
• Seizures
  
  
• Pale or brownish-yellowish skin
  
  
• Decreased sensation in the hands, feet or other areas
  
  
• Weakness, fatigue and lethargy
  
  
• Loss of appetite
  
  
• Unexplained weight loss

Diagnosis of end-stage renal disease (ESRD) typically requires the physician’s review of the patient’s medical history as well as a physical examination. A patient with a history of chronic kidney disease that has progressed may be suspected of having ESRD. The physical examination includes tests to determine the advancement of the kidney disease and will likely include a measurement of a patient’s blood pressure. Additional tests that may be performed include:

• Waste product tests. Blood tests for serum creatinine, blood urea nitrogen (BUN) and other waste products indicate the filtration capacity and health of the kidneys.
  
  
• Glomerular filtration rate (GFR). An indirect measurement of kidney filtering function. GFR traditionally required an injection of a substance into the patient’s body, followed by analysis of a 24-hour urine sample. However, GFR may now be estimated based on the results of a blood test. ESRD is indicated by a GFR of less than 15 milliliters per minute, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).
  
  
• Microalbuminuria test. Urine test that detects small amounts of protein. To detect early kidney disease, the American Diabetes Association recommends that people with type 2 diabetes be tested for microalbuminuria at the time of their diagnosis and then annually thereafter. People with type 1 diabetes should be tested five years after being diagnosed and then once a year thereafter.
  
  
• Urinalysis. Standard test that will detect larger amounts of protein in the urine (proteinuria), an indicator of severe kidney disease.

For patients with end-stage renal disease (ESRD), the damage already done to the kidneys is irreversible. Dialysis and kidney transplant are the only two options available for treating ESRD. These treatment options are also known as renal replacement therapy. Which method is used may depend on a patient’s general health and other factors. Both methods are expensive. Left untreated, patients with ESRD will die.

Dialysis is the most common treatment for ESRD. It replaces the filtration activity of the kidneys and cleans the blood of waste products. The physician will work with the patient to determine which type - hemodialysis or peritoneal dialysis - is best for the patient’s condition.

Long-term effects of dialysis include bone disease, high blood pressure, nerve damage and anemia (reduced red blood cell or hemoglobin levels). However, some of these consequences can be alleviated with treatment.

Kidney transplants are becoming the preferred treatment method for many patients with ESRD. Although dialysis prolongs life, it does not cure ESRD, and eventually most patients with the condition require a kidney transplant. This procedure gives the patient a healthy kidney from a living donor or a cadaver. Transplanted kidneys usually begin working within days, if not immediately. A successful transplant will prolong the patient’s life, and the replacement kidney may last five to 15 years, according to the Juvenile Diabetes Research Foundation. However, following the transplant, the patient must use immunosuppressives to reduce the risk of the immune system rejecting the new organ. These medications must be taken for life, and may make the patient more susceptible to complications including infections, some cancers, osteoporosis, glaucoma and cataracts.

Additional treatments may be recommended in conjunction with dialysis or kidney transplant. These may depend on the cause of a patient’s ESRD and a patient’s symptoms. For example, certain medications may be recommended for patients with high blood pressure. ACE inhibitors and angiotensin-II receptor blockers (ARBs) appear to be the most effective antihypertensives in reducing the decline of kidney function than other antihypertensives, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Glycemic control may be recommended for patients with diabetes. Blood transfusions may be necessary to control anemia in some patients.

Lifestyle changes may also be recommended as a concurrent treatment for patients with ESRD. Some changes the patient may need to make include:

• Reduced protein, potassium and phosphorus in the diet
  
  
• Limited fluid intake
  
  
• Medications to control blood pressure, regulate fluid levels and reduce anemia

End-stage renal disease (ESRD) may be delayed or prevented in some cases. Appropriate, early treatment of chronic kidney disease can sometimes help prevent its progression to ESRD. However, in some cases, prevention is not possible.

Other useful methods are those that help patients manage their diabetes and other conditions that can lead to ESRD. Regular checkups and screenings can help monitor the functioning of a person’s kidneys. Kidney damage develops over time, and symptoms typically do not occur until considerable damage has occurred.

Controlling glucose (blood sugar) helps maintain kidney health in patients with diabetes. Controlling high blood pressure (hypertension) is also closely linked with reducing the progression of kidney disease. High blood pressure may be treated with reduction of dietary sodium (salt), exercise, weight loss and antihypertensives, such as ACE inhibitors or angiotensin-II receptor blockers.

Dietary reductions in salt and protein intake reduce proteinuria and slow the loss of kidney function. Also, low amounts of protein in the diet reduce damage to the nephrons (filtering units) and glomeruli in the kidneys. A registered dietitian familiar with the needs of the patient can help customize meal planning and dietary guidelines.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about end-stage renal disease (ESRD):

1. Why do you think I have ESRD?
   
   
2. Could there be other causes for my symptoms?
   
   
3. Can I do anything to ease the damage of ESRD?
   
   
4. What tests are needed to monitor my ESRD, and how often should they be performed?
   
   
5. Are there any medications to help my ESRD?
   
   
6. Which are the advantages and disadvantages of dialysis? What type of dialysis is best for my condition?
   
   
7. What are the chances of getting a kidney transplant? What are its advantages and disadvantages?
   
   
8. How long do I have before I must get a kidney transplant?
   
   
9. What are the advantages of getting a kidney and pancreas transplant at the same time to also treat my diabetes? What are the disadvantages?
   
   
10. What are the risks of the immunosuppressive medications that are required after a transplant? Are there ways I can reduce these risks?