End-stage kidney disease (ESKD), often referred to as end-stage renal disease (ESRD), represents the final, most severe phase of chronic kidney disease (CKD).

At this stage, kidney function is critically diminished, and the body is unable to adequately filter waste products and maintain essential fluid and electrolyte balances.

What is End-Stage Kidney Disease?

End-stage kidney disease occurs when kidney function drops below 10 to 15 percent of normal capacity. The kidneys' ability to filter toxins, excess fluids, and maintain chemical balance becomes insufficient to support overall health.

This stage commonly follows years of gradual decline caused by conditions such as diabetes, hypertension, glomerulonephritis, or polycystic kidney disease. Complications escalate as the ability to remove metabolic waste fails, resulting in toxin accumulation known as uremia, which disrupts multiple body systems.

This critical stage is life-threatening and is marked by a shift from kidney damage to near or complete kidney failure. Without intervention, failure can lead to death, underscoring the importance of timely diagnosis and therapy.

Recognizing the Symptoms of ESKD

Symptoms of end-stage kidney disease often reflect systemic toxicity and fluid imbalance. Fatigue and generalized weakness are common early complaints due to anemia and electrolyte disturbances. Digestive symptoms such as nausea, vomiting, and loss of appetite frequently develop, contributing to malnutrition and weight loss.

Edema, or swelling predominantly seen in the legs, feet, and around the eyes, occurs due to fluid retention. Patients may experience difficulty breathing due to fluid accumulation in the lungs (pulmonary edema) or around the heart (pericardial effusion). Changes in skin pigmentation and persistent itching result from toxin buildup.

Neurologic manifestations such as difficulty concentrating, memory impairment, muscle cramps, and restless leg syndrome highlight the pervasive effect of waste accumulation on the nervous system. In some cases, patients experience headaches, sleep disturbances, and mood changes.

Causes and Progression

Multiple chronic conditions can lead to end-stage kidney disease. Diabetes remains the leading cause worldwide, where high blood sugar damages kidney filtering mechanisms over time. Hypertension exacerbates damage by increasing pressure within the kidneys’ filtering units.

Other causes include chronic glomerulonephritis, inherited disorders like polycystic kidney disease, and long-term obstruction of urinary flow.

Progression to ESKD is gradual, often spanning years during which kidney function steadily deteriorates. This slow progression allows compensatory mechanisms to mask symptoms initially. However, once filtering capacity falls into the critical threshold, symptoms become overt, signaling urgent need for intervention.

Treatment Options and Management Strategies

The primary life-sustaining treatments for ESKD include renal replacement therapies such as dialysis and kidney transplantation. Dialysis mechanically removes waste products and excess fluid, either through hemodialysis (using a machine to filter blood) or peritoneal dialysis (using the abdominal lining as a filter).

While dialysis sustains life, it is accompanied by lifestyle alterations and potential complications.

Kidney transplantation offers prospect for improved quality of life and survival, but requires suitable donor and lifelong immunosuppression to prevent rejection. Given the scarcity of donor kidneys, most patients begin dialysis while awaiting transplantation.

Management of ESKD also involves strict control of blood pressure, addressing anemia with erythropoiesis-stimulating agents, maintaining electrolyte balance, and appropriate nutritional support. Symptom control for itching, nausea, and fluid overload is essential to improve comfort.

Psychological and Social Impact

Beyond the physical burden, ESKD exerts significant psychological stress due to chronic illness, dependency on treatments, and lifestyle disruptions. Depression and anxiety are common, necessitating integrated mental health support. Social challenges include employment difficulties and financial strain from ongoing medical costs. Comprehensive care models addressing emotional, social, and physical needs yield better outcomes.

"Significant advances have been made specifically in the detection of antibodies toward kidney transplants. The testing has become much more sensitive, and so now we're able to avoid transplants that may lead to an early rejection." says Dr. Carrie Schinstock, Medical Director, Kidney Transplant Program, Mayo Clinic.

End-stage kidney disease is a critical, advanced stage of chronic kidney failure marked by severe functional decline. Manifesting through systemic symptoms like fatigue, fluid overload, digestive disturbances, and neurological impairment, ESKD demands prompt and sustained treatment primarily through dialysis or transplantation. Understanding causative factors highlights the importance of preventive care in chronic kidney disease.