End-Stage Renal Disease (ESRD) defines the final stage of long-term kidney failure, where the organs function at only 10 to 15 percent of their normal capacity or less. At this point, the kidneys can no longer adequately filter the blood, remove waste products, or balance fluids and electrolytes. Dialysis is a life-sustaining medical procedure that takes over these functions, artificially clearing the blood to prevent the buildup of toxic substances and excess fluid. Discontinuing dialysis is a choice that limits life, as the body can no longer manage its internal environment, leading inevitably to death if the treatment is not resumed.
Uremic Syndrome: The Accumulation of Waste Products
When dialysis is stopped, the body immediately begins to accumulate nitrogenous waste products, such as urea and creatinine, which are normally filtered and excreted by healthy kidneys. This toxic buildup in the bloodstream is known as uremic syndrome, or uremia, which signifies “urine in the blood.” The effects of uremia can initially manifest as vague, generalized symptoms that progressively worsen as toxin concentrations rise.
One of the earliest and most common complaints is severe fatigue and weakness. The high level of toxins interferes with normal bodily processes. Gastrointestinal symptoms are also prominent, including persistent nausea, vomiting, and a significant loss of appetite.
Patients may also experience problems with concentration and memory. Intense, generalized itching, known as pruritus, is caused by irritating substances deposited in the skin. A condition called uremic frost can occur, where crystallized urea deposits on the skin after sweat evaporates.
Acute Life Threats: Fluid Overload and Hyperkalemia
Two immediate, life-threatening crises result from the kidney’s inability to regulate body volume and electrolytes. The first is fluid overload, as the body can no longer excrete consumed water. This excess fluid rapidly causes swelling, or edema, and increases the overall blood volume.
The most dangerous consequence of fluid overload is pulmonary edema, where excess fluid is forced into the air sacs of the lungs. This causes severe shortness of breath and respiratory distress, making breathing difficult even at rest. The increased fluid volume also strains the heart, leading to high blood pressure.
The second acute threat is hyperkalemia, a high concentration of potassium in the blood. Potassium is an electrolyte that plays a direct role in the electrical signaling of nerve and muscle cells. Uncontrolled buildup of potassium quickly disrupts the heart’s normal rhythm, leading to potentially fatal cardiac dysrhythmias and rapid cardiac arrest.
Neurological and Cardiopulmonary System Failure
Sustained uremic toxicity and metabolic imbalances lead to systemic failure affecting the brain and heart. The buildup of toxins and the inability to excrete acid results in metabolic acidosis, which severely affects the central nervous system. This condition is known as uremic encephalopathy.
Early neurological symptoms include confusion, difficulty thinking, and disorientation, which can progress to tremors and muscle twitching. As toxicity increases, the patient may experience seizures. They eventually slip into a deep, unresponsive state known as a coma.
The cardiovascular system also suffers from chronic inflammation induced by uremia. One specific complication is uremic pericarditis, the inflammation of the sac surrounding the heart, causing chest pain and interfering with normal function. Ongoing fluid overload and difficult-to-control hypertension place immense stress on the heart muscle, accelerating heart failure.
Timeline and End-of-Life Medical Decisions
The time a person survives after stopping dialysis can vary significantly. For many patients who have minimal to no urine output, survival is often measured in days to a few weeks. Some individuals may live for up to several weeks if they retain some minimal filtering capacity.
The decision to stop dialysis shifts the focus of care from life-prolonging treatment to comfort and dignity. This involves Palliative Care or Hospice services. Palliative care focuses on managing the symptoms of the underlying disease and ensuring comfort.
Medical professionals use specific medications to manage common symptoms of decline, such as breathlessness from fluid in the lungs, nausea, and agitation or confusion. The body’s own rising level of toxins often induces a natural sleepiness, leading to unconsciousness before death. This process is typically calm.