ESRD stands for end-stage renal disease, the most advanced form of chronic kidney disease. It means the kidneys have lost nearly all their ability to filter waste and excess fluid from the blood, functioning at less than 15% of normal capacity. At this point, a person needs dialysis or a kidney transplant to survive. Over 856,000 people in the United States are currently living with ESRD.
How ESRD Is Defined and Diagnosed
ESRD is classified as Stage 5 chronic kidney disease (CKD), the final stage on a five-stage scale. Doctors measure kidney function using a blood test called the estimated glomerular filtration rate, or eGFR, which reflects how well your kidneys filter waste. A healthy eGFR is above 90. An eGFR below 15, confirmed with repeat testing over at least three months, indicates ESRD. If someone is already on dialysis, they’re also classified as having ESRD regardless of their eGFR number.
The repeat testing requirement exists to rule out acute kidney injury, a sudden but potentially reversible drop in kidney function caused by dehydration, infection, or medication reactions. ESRD, by contrast, represents permanent damage.
In medical billing and records, ESRD is coded as N18.6 under the ICD-10 system, which hospitals and insurers use to classify diagnoses.
What Causes Kidneys to Reach This Stage
Diabetes and high blood pressure are the two most common causes of kidney disease in the United States, and they’re responsible for the vast majority of ESRD cases. Diabetes damages the tiny blood vessels inside the kidneys over years, gradually reducing their filtering ability. High blood pressure does something similar, putting constant strain on those same delicate structures until they scar and stop working.
Other conditions that can lead to ESRD include polycystic kidney disease (an inherited condition that causes fluid-filled cysts to grow in the kidneys), chronic infections, autoimmune diseases that attack kidney tissue, and long-term obstruction of the urinary tract. Some people reach ESRD from a combination of factors.
Racial and ethnic disparities shape who develops ESRD and why. Black Americans are more likely to develop ESRD from high blood pressure than White or Hispanic Americans. Hispanic Americans are more likely to reach ESRD from diabetes than either White or Black Americans. These patterns reflect differences in disease prevalence, access to early treatment, and genetic susceptibility.
What ESRD Feels Like
When kidneys can no longer clear waste from the blood, a condition called uremia develops. Waste products build up to toxic levels and affect nearly every system in the body. Early symptoms include persistent nausea, vomiting, loss of appetite, unexplained weight loss, and deep fatigue that rest doesn’t fix. Muscle cramps, intense itching, and increased thirst are also common.
As uremia worsens, it affects the brain and nervous system. People may experience confusion, difficulty concentrating, visual disturbances, and changes in mental status. The skin can take on a yellowish or darkened tone. In severe, untreated cases, urea crystals can actually deposit on the skin’s surface, a phenomenon historically called “uremic frost.”
Fluid retention is another hallmark of ESRD. When the kidneys can’t remove excess water, it accumulates in the body, causing swelling in the legs and ankles and potentially backing up into the lungs. This fluid overload can worsen blood pressure and strain the heart, sometimes leading to heart failure. Dangerous shifts in blood electrolytes, particularly potassium, can cause irregular heart rhythms or cardiac arrest if left untreated.
Treatment: Dialysis Options
Dialysis takes over the kidney’s filtering job, removing waste and excess fluid from the blood mechanically. There are two main types, and each fits different lifestyles.
In-center hemodialysis is the most common form. You travel to a dialysis center three times per week, where trained staff connect you to a machine that draws your blood through a filter and returns it cleaned. Sessions typically last three to four hours. About 63% of all ESRD patients in the U.S. are on some form of dialysis.
Home hemodialysis works the same way but happens at your home, usually five to seven times per week in shorter sessions. It requires dedicated space for a machine and supplies, and in most cases a partner must be present during treatment. Special plumbing or electrical modifications may be needed.
Peritoneal dialysis uses the lining of your abdomen as a natural filter instead of a machine. A catheter is surgically placed in the belly, and a special fluid is pumped in, absorbs waste, and is drained out. This is done every day, but it’s portable and doesn’t require a dialysis machine. The tradeoff is that it requires storage space for supplies and carries a risk of infection at the catheter site.
Kidney Transplant as an Alternative
A kidney transplant replaces the failed organ with a healthy one from a living or deceased donor. It’s not just an alternative to dialysis; it offers a significant survival advantage. For a woman between 55 and 59, a transplant provides nearly 9 additional years of life compared to staying on dialysis. For a man the same age, the benefit is over 7 years. Kidneys from living donors tend to last longer and produce better outcomes than those from deceased donors.
Not everyone qualifies. To be listed for a transplant, your kidney function generally needs to be at or below a GFR of 20. Beyond that, you must be healthy enough to survive major surgery and tolerate lifelong immune-suppressing medications. Conditions that can disqualify someone include a BMI over 45, active substance use disorders, severe heart or lung disease, untreated mental health conditions that would interfere with post-transplant care, cancer likely to worsen after transplant, and a life expectancy under five years even with a new kidney. Lack of insurance or an inability to cover transplant-related costs can also be a barrier.
About 37% of people living with ESRD in the U.S. have a functioning kidney transplant. The rest remain on dialysis, often while waiting for a donor organ. Wait times vary widely by region but commonly stretch several years.
Long-Term Outlook
ESRD is a serious, life-shortening condition, but survival has improved significantly over the decades thanks to advances in dialysis technology and transplant medicine. Five-year survival rates vary depending on the type of treatment. People who receive a transplant consistently have better survival than those on dialysis, and living-donor transplants outperform deceased-donor transplants.
One sobering trend: five-year survival was actually slightly lower for people who reached ESRD in 2017 compared to 2012, regardless of treatment type. The COVID-19 pandemic further increased mortality among ESRD patients in 2020 and 2021, as this population is especially vulnerable to infections. Even so, the survival advantage of transplantation over dialysis held steady through the pandemic.
Quality of life also differs between treatments. Many transplant recipients return to work and daily routines with fewer restrictions. Dialysis patients often manage significant fatigue and time commitments, especially with in-center treatment. Home-based options, whether hemodialysis or peritoneal dialysis, offer more flexibility but require daily commitment and self-management.