End-stage renal disease (ESRD) is the final stage of chronic kidney disease, where the kidneys function at less than 10 to 15 percent of their normal capacity. At this stage, the kidneys can no longer adequately perform their life-sustaining functions, such as filtering waste products and excess fluid from the blood. Dialysis acts as an artificial replacement, using a machine or the patient’s peritoneal membrane to remove accumulated toxins and regulate the body’s balance of electrolytes and fluid. This treatment is necessary for survival; without it, waste products and water quickly build up to dangerous levels in the bloodstream, a condition known as uremia. Missing prescribed dialysis treatments immediately interrupts this filtration process, rapidly leading to severe health crises.
Acute Physical Effects of Missing Treatment
The immediate consequence of skipping a dialysis session is the rapid accumulation of fluid and metabolic waste products that the body cannot excrete. Within hours to a couple of days, the patient may begin to feel profound physical discomfort due to this buildup. Severe fatigue is one of the most noticeable symptoms, often accompanied by a general feeling of being unwell as toxins like urea overload the system.
The buildup of nitrogenous waste products causes uremia, leading to symptoms like persistent nausea and vomiting. Excess water retention compounds this, resulting in significant peripheral edema, particularly in the legs, ankles, and feet. This fluid retention also raises blood pressure, putting extra strain on the cardiovascular system.
As the fluid overload worsens, it begins to affect the lungs, causing pulmonary edema. The patient will experience shortness of breath because excess fluid leaks into the air sacs (alveoli), making oxygen absorption difficult. The sudden onset or worsening of breathlessness is a clear warning sign of a life-threatening complication.
Rapid Progression to Organ Failure
If the missed dialysis is not corrected, escalating fluid and toxin levels lead to life-threatening internal crises, primarily involving the heart and brain. One of the most immediate and dangerous threats is hyperkalemia, a high level of potassium in the blood. Since the failed kidneys cannot excrete potassium, and dialysis is the only means of removal, a missed session allows this electrolyte to climb rapidly, often becoming the direct cause of death.
Potassium is essential for regulating electrical signals in the heart muscle, and excess levels disrupt the normal rhythm. Hyperkalemia can cause cardiac dysrhythmias, which may be seen as peaked T-waves and a widening QRS complex on an electrocardiogram. These abnormalities can quickly progress to fatal heart rhythms, such as ventricular fibrillation or asystole, leading to cardiac arrest.
Simultaneously, unchecked fluid volume overwhelms the circulatory system, drastically worsening pulmonary edema and leading to respiratory failure. The lungs become congested, the patient struggles to breathe, and oxygen levels drop precipitously. This severe fluid overload puts extreme pressure on the heart, often accelerating congestive heart failure.
The accumulation of uremic toxins also directly affects the central nervous system, leading to uremic encephalopathy. These toxins impair brain function, initially causing confusion, disorientation, and agitation. As toxicity increases, the patient may experience muscle twitching, seizures, and eventually slip into a coma.
Medical Management When Dialysis Stops
For patients facing a declining quality of life, the intentional decision to cease dialysis is a recognized medical choice, distinct from accidentally missing a session. This transition is usually made through shared decision-making involving the patient, their family, and a medical team. When this choice is made, the focus of care shifts entirely from life-prolonging treatment to comfort and dignity, a process known as palliative care.
The medical team works to manage the physical symptoms that arise from the inevitable buildup of toxins and fluid. The goal is to ensure the patient remains comfortable, peaceful, and free from distress during the end-of-life process, which typically occurs within a few days to a couple of weeks. Palliative measures specifically target symptoms like pain, anxiety, and breathlessness.
Symptom management requires careful adjustment of medications, as many drugs are normally cleared by the kidneys and can build up once dialysis stops. Opioids like fentanyl and buprenorphine are considered safer choices for pain relief compared to others that produce toxic metabolites. Benzodiazepines may be used to manage anxiety, agitation, and restlessness, while concentrated diuretics can sometimes offer comfort from volume overload if the patient has some residual urine output.
The care plan also addresses emotional and spiritual support for both the patient and their family, often involving hospice services. The team counsels families on what to expect, assuring them that symptoms can be effectively treated to allow for a peaceful passing. This deliberate cessation of treatment allows the patient to prioritize comfort and quality of remaining time.