End stage renal disease (ESRD) means your kidneys have lost nearly all their ability to function, dropping below roughly 15% of normal filtering capacity. At this point, your kidneys can no longer keep you alive on their own, and you need either dialysis or a kidney transplant to survive. It is the final stage (Stage 5) of chronic kidney disease, and as of 2023, more than 831,000 Americans are living with it.
How Kidney Function Is Measured
Doctors track kidney health using a number called the estimated glomerular filtration rate, or eGFR. This measures how efficiently your kidneys filter waste from your blood, expressed in milliliters per minute. A healthy eGFR is above 90. An eGFR below 15 is classified as Stage 5 chronic kidney disease, which is the clinical threshold for ESRD. Some people reach this stage gradually over years; others arrive more quickly depending on the underlying cause.
Reaching an eGFR below 15 doesn’t always mean you’ll feel dramatically different overnight. Many people have been slowly losing kidney function for a long time, and their bodies have partially adapted. But at this level, waste products, excess fluid, and electrolytes are building up faster than your kidneys can handle, and treatment becomes necessary.
What Happens Inside Your Body
Healthy kidneys do far more than make urine. They balance fluid levels, regulate blood pressure, maintain the right concentration of minerals like potassium and phosphorus, help produce red blood cells, and keep your bones strong. When they fail, all of these systems are affected simultaneously.
The most immediate danger is the buildup of waste products in your blood, a condition called uremia. Fluid retention causes swelling in the arms and legs and can push fluid into the lungs, making it hard to breathe. Potassium levels can spike suddenly, which is dangerous because potassium directly affects heart rhythm. Blood pressure often becomes very difficult to control, even with medication. Over time, the disruption in phosphorus and calcium balance triggers your parathyroid glands to overwork, gradually weakening your bones.
Symptoms of Kidney Failure
The symptoms of ESRD reflect the toxic buildup happening throughout your body. Common ones include persistent nausea and vomiting, loss of appetite, unintentional weight loss, extreme fatigue, muscle cramps, and intense itching. Some people notice changes in mental clarity, difficulty concentrating, or visual disturbances. Increased thirst is common even as the body retains too much fluid.
In more advanced cases, physical signs become visible. Skin may take on a yellowish or darkened tone. In rare, severe situations, tiny urea crystals can appear on the skin’s surface. Gum problems, including bleeding and overgrowth, sometimes develop. Fluid around the heart (pericardial effusion) can occur, and spontaneous bleeding, including in the gastrointestinal tract, becomes a risk. These symptoms don’t all appear at once, and their severity varies from person to person.
Treatment: Dialysis
Once kidneys can no longer sustain life, dialysis takes over part of their job by artificially filtering waste and excess fluid from your blood. There are two main types, and which one you use depends on your health, lifestyle, and personal preference.
In-center hemodialysis is the most common form. You travel to a dialysis center at least three times a week, where trained staff connect you to a machine that draws your blood, filters it, and returns it to your body. Sessions typically last several hours. You’re in a room with other patients, so privacy is limited, and family members generally can’t be present during treatment.
Home hemodialysis follows the same principle but happens in your own home, usually five to seven times per week in shorter sessions. You and a partner are trained to operate the equipment. A dedicated space in your home is needed for the machine and supplies, and special plumbing or electrical work may be required. A dialysis partner must be present during every session.
Peritoneal dialysis works differently. Instead of filtering blood through a machine, a cleansing fluid is introduced into your abdomen through a surgically placed catheter. The lining of your abdominal cavity acts as the filter. This is done every day, with no days off, but it doesn’t require a machine and offers more flexibility. The main risks are infection around the catheter site and the psychological adjustment to a visible catheter.
Five-year survival on dialysis is roughly 40 to 42%, depending on the type. These numbers have remained relatively stable over the past decade.
Treatment: Kidney Transplant
A kidney transplant is the other major treatment option, and for many people it offers a better long-term outlook. Five-year survival after receiving a kidney from a living donor is about 91%. For a deceased donor kidney, it’s around 80%. Both figures are significantly higher than long-term dialysis survival.
Not everyone qualifies. To be eligible, you need to be healthy enough to tolerate major surgery, and you can’t have certain conditions that wouldn’t improve with a transplant, such as certain active cancers, untreatable infections, or severe heart disease. You also need a support system: most transplant programs require a care partner, someone who helps manage medications, drives you to follow-up appointments, and can contact your medical team if something goes wrong.
After a transplant, you’ll take anti-rejection medications for the rest of your life to prevent your immune system from attacking the new kidney. This requires consistent medical follow-up and carries financial responsibilities that you and your family need to be prepared for before being placed on the waiting list.
Diet and Daily Management
What you eat matters enormously with ESRD, particularly if you’re on dialysis. Your kidneys can no longer regulate potassium, phosphorus, or sodium on their own, so your diet has to do some of that work. Foods high in potassium (bananas, oranges, potatoes, tomatoes) and phosphorus (dairy, processed foods, dark colas) often need to be limited. Salt substitutes are particularly risky because they replace sodium with potassium. Even milk is typically restricted to about half a cup per day on hemodialysis.
There’s no single set of universal limits because the right targets depend on your lab results, the type of dialysis you’re on, and your body size. A renal dietitian works with you to build an individualized eating plan and adjusts it over time as your numbers change. Fluid intake is also usually restricted, since your kidneys are no longer removing excess water effectively.
Medicare Coverage for ESRD
In the United States, ESRD qualifies you for Medicare regardless of your age. This is one of the very few conditions that triggers Medicare eligibility outside the standard age requirement. To qualify, your kidneys must no longer function adequately, and you must need regular dialysis or have received a kidney transplant. You also need to have worked enough under Social Security (or be the spouse or dependent child of someone who has), or already be receiving Social Security or Railroad Retirement benefits. This coverage helps offset the significant costs of dialysis treatments, transplant surgery, and ongoing medications.
How Common ESRD Is
The total number of Americans living with kidney failure reached 831,192 in 2023, an all-time high. About 131,564 new cases were diagnosed that year. However, the picture is more nuanced than rising totals suggest: after adjusting for population changes in age, sex, and race, the rate of new cases actually fell 21% between 2003 and 2023, dropping from 456 to 362 per million people. More people are living with ESRD partly because treatments are keeping patients alive longer, and partly because the U.S. population is aging. The two most common underlying causes are diabetes and high blood pressure, which together account for the majority of cases.