Kidney Failure

IWBCA
Feb 13
17 min read

Kidney failure occurs when one or both kidneys can no longer adequately filter waste, balance fluids and electrolytes, or support normal body functions. It may develop suddenly after an acute injury or gradually through chronic kidney disease. Symptoms include fatigue, nausea, swelling, changes in urination, and difficulty thinking clearly. Treatment focuses on correcting reversible causes when possible and, in advanced stages, on dialysis or kidney transplantation to sustain life.

Overview

What is kidney failure?

Kidney failure, also called renal failure, means that one or both kidneys can no longer perform their essential functions well enough to meet the body’s needs. In acute kidney failure, this loss of function develops over hours to days, often after a severe illness, major surgery, medication toxicity, or a sudden drop in blood flow to the kidneys. In chronic kidney failure, kidney function declines slowly over months to years as part of chronic kidney disease, typically due to long-standing diabetes, high blood pressure, or other structural and inflammatory kidney disorders. When kidney function falls to the lowest stage, called end-stage kidney disease (ESKD), toxins, acid, and fluid build up to levels that become life-threatening without dialysis or transplant. With appropriate treatment, many people can maintain a meaningful quality of life even when their kidneys are no longer functioning independently.

Anatomy and Physiology

What do the kidneys do?

The kidneys are two bean-shaped organs, each about the size of a fist, located in the retroperitoneal space beneath the ribcage. Most people are born with two kidneys, although one healthy kidney can support normal life if it functions well. Inside each kidney, millions of tiny filtering units called nephrons continuously clean the blood. They remove waste products such as urea and creatinine, regulate water and electrolyte levels, maintain potassium homeostasis, regulate acid–base balance and blood pressure, and help control red blood cell production and bone health through hormone signaling. When kidney function declines, waste and fluid begin to accumulate, electrolytes drift out of range, and these regulatory systems become unstable. Over time, this can cause fatigue, nausea, itching, swelling, shortness of breath, confusion, and heart strain. Without timely treatment, severe kidney failure progresses to a state in which the body can no longer keep up, and survival becomes limited.

Prevalence

How common is kidney failure?

Kidney failure is a major public health problem. In the United States, hundreds of thousands of people live with kidney failure that requires dialysis or transplantation, and many more are approaching that stage as chronic kidney disease progresses. Worldwide, it affects several million individuals, with numbers rising because diabetes, high blood pressure, and aging populations are increasingly common. Many people reach advanced stages without realizing they have kidney disease, which is why routine blood and urine testing in at-risk groups is so important.

Stages

What are the five stages of kidney disease?

Kidney disease is staged using the estimated glomerular filtration rate (eGFR), a calculation derived from a blood test that contains creatinine and certain demographic factors. eGFR reflects the extent to which the kidneys filter blood per minute. In general, an eGFR above 90 milliliters per minute per 1.73 square meters is considered normal if no other signs of kidney damage are present, and an eGFR of 0 indicates no remaining filtration.

The five stages of chronic kidney disease are:

Stage I: eGFR is 90 or higher. There is evidence of kidney damage, such as protein in the urine or structural abnormalities on imaging, but overall filtration remains in the normal range. Many individuals have no symptoms at this stage, and the focus is on treating underlying conditions and preserving renal function.

Stage II: eGFR is 60 to 89. There is a mild reduction in kidney function along with evidence of kidney damage. Most people remain well, but careful monitoring of blood pressure, blood sugar, and medications is crucial to slow further decline.

Stage III: eGFR is 30 to 59. This stage is divided into IIIa (45–59) and IIIb (30–44) because risk increases as the function falls. Symptoms such as fatigue, swelling, sleep problems, or changes in urination may begin. Laboratory changes, including anemia, rising phosphorus levels, or low bicarbonate, often occur, and specialist kidney care is usually recommended.

Stage IV: eGFR is 15 to 29. Kidney function is severely reduced, and complications such as difficult-to-control blood pressure, worsening anemia, bone and mineral problems, and metabolic acidosis become more common. Many people in Stage IV start planning for possible dialysis, transplant evaluation, and vascular or access placement even if dialysis is not yet needed.

Stage V: eGFR is below 15. This is also called end-stage kidney disease. The kidneys are nearing or at complete failure, and symptoms often include profound fatigue, loss of appetite, nausea, itching, shortness of breath, confusion, and swelling. At this point, most people require dialysis or a kidney transplant to remove waste and excess fluid and to sustain life, unless there is a clear short-term reversible cause that can be corrected rapidly.

Understanding your stage, along with your symptoms and laboratory trends, helps your care team decide when to focus on prevention, when to prepare for advanced therapies, and when dialysis or transplant should be considered.

Symptoms and Causes

What are the first warning signs of kidney failure?

Many people with early chronic kidney disease have no obvious symptoms, even while measurable damage is already occurring. As kidney function falls further, waste products, excess fluid, and electrolyte imbalances begin to affect day-to-day life. Warning signs often begin subtly and can be easily attributed to age, stress, or other conditions; therefore, paying attention to patterns over time is important.

Extreme Tiredness (Fatigue): Fatigue from kidney failure is often deeper than ordinary tiredness. People describe feeling “drained” even after sleep, with less stamina for routine tasks, climbing stairs, or concentrating at work. This may reflect anemia, toxin accumulation, sleep disruption, and muscle wasting that occur as kidney function declines.

Nausea and Vomiting: As waste products accumulate in the blood, the digestive system can become irritated. You may notice a persistent unsettled stomach, loss of interest in food, queasiness when you smell certain foods, or vomiting that is not clearly tied to infections or food poisoning. Over time, this can lead to unintentional weight loss and weakness.

Confusion or Trouble Concentrating: Kidney failure can affect brain function. You may feel “foggy,” have difficulty focusing on conversations or reading, forget details more easily, or feel unusually slow in thinking through simple tasks. In advanced stages, confusion can become more pronounced, particularly when toxins and electrolyte levels are markedly abnormal.

Swelling (Edema) Around Hands, Ankles, or Face: When the kidneys cannot efficiently remove excess salt and water, fluid often accumulates in the tissues. This can cause puffiness around the eyes, swelling in the ankles or feet that worsens by evening, or tightness in rings and shoes. In more severe cases, fluid can accumulate in the lungs, causing shortness of breath.

Changes in How Often or How Much You Pee: You may notice that you are urinating more often at night, passing larger or smaller amounts than usual, or seeing foamy urine that suggests protein loss. In some forms of kidney injury, urine output drops sharply; in others, you may continue to produce urine even when filtration of waste is poor. Any persistent change from your usual pattern is worth discussing with a clinician.

Cramps and Muscle Spasms: Electrolyte imbalances, such as calcium, magnesium, and potassium, can cause muscle cramps, twitching, or spasms, particularly in the legs and feet. These may occur at night or with activity and can become more frequent as kidney function worsens.

Dry or Itchy Skin: Kidney failure often leads to changes in skin texture and sensation. Skin can become dry, flaky, and persistently itchy, sometimes to the point of scratching that breaks the skin. This is often associated with toxin accumulation, changes in sweat and sebum production, and shifts in mineral levels that affect nerves and small blood vessels in the skin.

Poor Appetite or Metallic Taste: Food may begin to taste “off,” bitter, or metallic, and familiar meals may become less appealing. You might feel full quickly or lose interest in eating altogether. This change in appetite, particularly when accompanied by nausea and weight loss, is a common sign that kidney dysfunction is affecting overall metabolism.

Causes

What are the most common causes of kidney failure?

Kidney failure is usually the result of long-term damage that has accumulated over the years. In many people, more than one factor is involved. Two conditions, diabetes and high blood pressure, account for most cases of chronic kidney disease that progress to kidney failure, but inherited and immune-mediated conditions are also important contributors.

Diabetes: Long-standing high blood sugar damages the small blood vessels and filtering units in the kidneys. Over time, these filters become scarred and leaky, allowing protein to spill into the urine and gradually reducing filtration capacity. Good blood sugar management can slow this process, but if hyperglycemia continues for years, diabetic kidney disease is a leading cause of chronic kidney failure.
High Blood Pressure (Hypertension): When blood pressure remains elevated, the force of blood flow puts continuous strain on the delicate vessels in the kidneys. This can thicken and narrow those vessels, limit blood flow, and injure the filtering structures. Uncontrolled high blood pressure is both a cause and a consequence of kidney disease, and without treatment, it accelerates progression toward kidney failure.
Polycystic Kidney Disease (PKD): PKD is an inherited condition in which numerous fluid-filled sacs, or cysts, slowly expand within the kidneys. These cysts distort normal kidney tissue, compress blood vessels, and reduce the amount of functioning nephron tissue. Even when blood pressure and blood sugar are well controlled, the mechanical burden of cyst growth can eventually lead to kidney failure.
Glomerular Diseases: Glomerular diseases affect the tiny filters (glomeruli) that remove waste and excess fluid from the blood. They may result from immune reactions, infections, medications, or unknown triggers. Over time, ongoing inflammation and scarring in the glomeruli can reduce filtration, cause protein loss into the urine, and ultimately contribute to chronic kidney failure if not recognized and treated.
Autoimmune Kidney Diseases: In autoimmune diseases such as lupus, the immune system attacks the body’s own tissues, including structures within the kidneys. Immune complexes and inflammatory cells can damage both glomeruli and the surrounding tissue. Without effective control of the autoimmune activity, this ongoing injury can lead to progressive chronic kidney disease and eventual kidney failure.
Other Chronic Kidney Injuries: Long-standing obstruction of urine flow, recurrent kidney infections, certain medications, and prolonged exposure to toxins can all damage kidney tissue over time. In many cases, the injury accumulates silently until eGFR has already fallen significantly. Early recognition and removal of these chronic stressors can reduce the risk of kidney failure.
Acute Kidney Failure (Acute Kidney Injury): Not all kidney failure develops slowly. Acute kidney failure occurs when the kidneys suddenly lose much of their function over hours to days. This can happen even in people whose kidneys were previously normal. Common triggers include severe dehydration, major infections, large blood loss, reactions to certain medications, or blockages that abruptly obstruct urine flow. In some cases, acute kidney failure is temporary and improves with prompt treatment. In others, it leaves permanent damage that increases the risk of later chronic kidney failure.
Common Causes of Acute Kidney Failure: Medications that reduce blood flow to the kidneys or directly injure kidney cells, such as certain anti-inflammatory drugs, certain antibiotics, contrast agents, and chemotherapy agents, can cause acute kidney injury in susceptible individuals. Severe dehydration from vomiting, diarrhea, or poor fluid intake reduces blood volume and can starve the kidneys of adequate blood flow. Blockages in the urinary tract, such as an enlarged prostate, kidney stones, or tumors, can obstruct urine flow and cause increased pressure in the kidneys. Untreated systemic diseases, including advanced heart or liver failure, can impair kidney perfusion and lead to rapid loss of function.

Risk Factors

What are the risk factors for kidney failure?

Kidney failure can occur in anyone, but some people have a much higher likelihood because of underlying health conditions, genetic background, or environmental exposures. Knowing your risk factors helps determine how often your kidneys should be checked and how aggressive prevention efforts should be.

Diabetes: Having Type 1 or Type 2 diabetes is one of the strongest risk factors for chronic kidney disease. The longer blood sugar has been elevated and the less tightly it is controlled, the higher the chance that diabetic kidney damage will occur. Regular monitoring of urine protein and eGFR is especially important in this group.
High Blood Pressure (Hypertension): Persistent high blood pressure stresses the kidney blood vessels and filtering units. People with hypertension, especially when readings are frequently above target or require multiple medications to control, have a substantially higher risk of progressing to kidney failure over time if blood pressure remains uncontrolled.
Heart Disease: Conditions such as heart failure, coronary artery disease, and long-standing vascular disease impair blood flow and oxygen delivery throughout the body, including to the kidneys. Reduced cardiac output and vascular injury make it harder for the kidneys to maintain normal filtration and make them more vulnerable to further insults.
Family History of Kidney Disease: A close relative with kidney disease, particularly at a younger age, suggests a genetic or shared environmental contribution. This is especially relevant in inherited disorders such as PKD and certain glomerular diseases. In these situations, earlier and more frequent kidney monitoring is often recommended.
Abnormal Kidney Structure: Being born with a single kidney, having small or malformed kidneys, or having structural issues in the urinary tract can limit reserve from the outset. These anatomic differences can increase susceptibility to chronic injury from infections, obstruction, or other stressors and raise the risk of earlier kidney failure.
Race and Ethnicity: In many countries, Black individuals and some other racial and ethnic groups experience higher rates of kidney failure. This reflects a combination of genetic susceptibility, including APOL1 risk variants in some people of African ancestry, and powerful social factors such as differences in access to care, nutrition, and exposure to chronic stress and environmental hazards.
Older Age: Being over 60 increases risk because kidney function gradually declines with age and because older adults are more likely to have diabetes, hypertension, and heart disease. Age alone does not cause kidney failure, but it lowers the reserve available to tolerate additional insults.
Long-Term Use of Certain Pain Relievers: Regular, long-term use of some over-the-counter and prescription pain medicines, particularly nonsteroidal anti-inflammatory drugs (NSAIDs), can reduce blood flow to the kidneys and cause gradual structural damage. This risk is higher in people who already have reduced kidney function, heart failure, dehydration, or other serious illnesses.

Recognizing these risk factors and discussing them with a clinician allows for earlier screening, more tailored prevention strategies, and faster intervention if kidney function begins to decline.

Management and Treatment

How is kidney failure treated?

Kidney failure cannot be “cured” in the sense of restoring normal kidney structure, but it can be treated and managed. The goals are to slow any further loss of function, control symptoms and complications, and, when kidneys can no longer provide adequate filtration, replace their work with dialysis or a transplant. The exact plan depends on whether kidney failure has developed suddenly or gradually, how much function remains, and what other conditions you live with.

When kidneys are declining slowly, clinicians focus first on preserving remaining function and monitoring the rate of change. This usually involves regular blood and urine tests, blood pressure checks, medication review, and close attention to symptoms such as swelling, breathlessness, and changes in appetite and energy.

Ongoing Monitoring and Supportive Care: Regular blood tests are used to follow creatinine, estimated glomerular filtration rate (eGFR), electrolytes, acid–base balance, hemoglobin, and markers of bone and mineral metabolism. Blood pressure monitoring and medication adjustments aim to maintain blood pressure within the range most likely to protect both the heart and the kidneys. Diet, fluid intake, and salt use are tailored to your stage of kidney disease and your specific complications, such as swelling, high potassium, or metabolic acidosis. This stage is often managed jointly by your primary care clinician and a nephrologist.

Medications For Kidney Failure: Depending on the cause of your kidney disease and your current complications, your care team may recommend one or more categories of medicines. These do not fix damaged tissue, but they can slow further damage and treat the consequences of reduced function.

ACE Inhibitors and ARBs: Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) lower blood pressure and reduce pressure within the kidney's glomeruli. They are often used when protein is leaking into the urine, because they can reduce that leak and slow scarring. Doses are adjusted carefully as kidney function changes, and potassium levels are monitored, because these drugs can increase potassium and creatinine in some people.

Diuretics: Diuretics increase urine output and help remove excess salt and water from the body. They are used to control swelling in the legs, abdomen, or lungs and to relieve shortness of breath associated with fluid overload. Choices include “water pills” such as loop diuretics and thiazides; which one is used, and at what dose, depends on kidney function, blood pressure, and other heart and vascular issues.

Statins and Other Lipid-Lowering Medicines: Statins reduce cholesterol and lower the risk of heart attack and stroke, which are major causes of illness and death in people with chronic kidney disease. They are often used even when cholesterol is only moderately elevated because kidney failure itself increases cardiovascular risk.

Erythropoiesis-Stimulating Agents and Iron Therapy: When kidney failure causes anemia by reducing erythropoietin production, your provider may prescribe injectable medicines that stimulate red blood cell production, often combined with iron supplements. The aim is to reduce fatigue and improve exercise tolerance while avoiding hemoglobin levels that could increase cardiovascular risk.

Vitamin D, Calcitriol, and Related Therapies: Active vitamin D analogs such as calcitriol, along with other medications that modify parathyroid hormone signaling, are used to manage bone and mineral disorders that arise in advanced kidney disease. They work alongside dietary phosphorus restriction and other measures to reduce bone loss, bone pain, and the risk of fractures.

Phosphate Binders: When the kidneys cannot excrete phosphorus effectively, phosphate binders taken with meals help trap phosphorus in the gut, reducing its absorption. Lowering phosphorus levels reduces itching, helps control parathyroid hormone levels, and protects bones and blood vessels from additional damage.

Dialysis: When kidney function falls below the level needed to safely remove waste and fluid, dialysis replaces much of the filtering work. Dialysis does not repair the kidneys, but it can control symptoms, correct many electrolytes and acid–base problems, and support life for years.

Hemodialysis: In hemodialysis, blood is drawn from your body, passed through a filter in a dialysis machine, and then returned. This process removes urea, creatinine, excess fluid, and other wastes several times a week. Most people receive hemodialysis three times per week in a dialysis center, with each session lasting several hours, although schedules can vary. Access to the bloodstream is usually provided by an arteriovenous fistula, graft, or catheter. Your care team adjusts the treatment time, fluid removal, and dialysate composition based on your weight, blood pressure, symptoms, and laboratory results.

Peritoneal Dialysis: Peritoneal dialysis uses the lining of your abdominal cavity as the filter. A soft catheter is surgically placed into the abdomen. Dialysis solution is infused through this catheter, allowed to dwell so that waste products and excess fluid move from your blood into the fluid, and then drained. This exchange is repeated several times per day or automatically overnight, depending on the prescribed method. Many people perform peritoneal dialysis at home, which can offer greater flexibility, but it requires training, strict hygiene, and storage space for supplies.

Kidney Transplant: A kidney transplant offers the possibility of more natural kidney function and greater freedom from dialysis for many people with end-stage kidney disease. It is a major surgical procedure that is not suitable for everyone; however, when successful, it can provide longer life expectancy and a more typical daily routine.

Transplant From A Deceased or Living Donor: In a kidney transplant, a surgeon places a healthy donor kidney into your body, usually in the lower abdomen, and connects it to your blood vessels and bladder. The diseased kidneys are usually left in place unless there is a specific indication for removal. Donor kidneys may come from a deceased donor or from a living donor who has been carefully evaluated. After transplantation, you will need lifelong immunosuppressive medications to prevent rejection and regular follow-up to monitor kidney function, drug levels, and side effects.

Conservative and Palliative Management: Not everyone is a candidate for dialysis or transplant, and some people choose not to pursue these options. In that setting, conservative management focuses on controlling symptoms, managing fluid and electrolyte balance as safely as possible, and supporting comfort and quality of life without using dialysis. Palliative care teams often work alongside nephrologists to address pain, shortness of breath, itching, sleep disturbance, and emotional and spiritual concerns.

Recovery

Can you recover from end-stage kidney failure?

By definition, end-stage kidney disease means that kidney function has fallen to a level where it cannot sustain life without replacement therapy. In most chronic cases, this loss of function is permanent. Dialysis and transplant do not make the kidneys “normal” again, but they can take over most of the critical tasks the kidneys once performed and allow many people to live for years or decades. The focus is on choosing a treatment path that matches your medical situation and your values, maintaining the best function possible in any remaining kidney tissue, and revisiting goals as your health and life circumstances evolve.

Outlook and Prognosis

What can I expect if I have kidney failure?

Kidney failure is not reversible, but it is treatable. Many people live for years with advanced kidney disease, work, spend time with family, and continue daily activities, especially when the condition is recognized early and managed systematically. What you can expect depends on your overall health, the cause of your kidney failure, how quickly your function is changing, and whether you pursue dialysis, transplant, or conservative (non-dialysis) care.

For some individuals, kidney function declines slowly and stabilizes for extended periods with careful blood pressure control, diabetes management, dietary modifications, and medications. Others move more quickly toward end-stage kidney disease and need dialysis or transplant to control symptoms such as fatigue, shortness of breath, nausea, itching, and swelling. Even after dialysis begins, function may continue to fluctuate, so your team will adjust your treatment plan based on lab results, your weight, blood pressure, and how you feel between treatments.

Quality of life is shaped by how well symptoms are managed, how well treatment fits into your daily routine, and the support you have from your care team and your personal network. Many people find that planning ahead for dialysis access, transplant evaluation, or palliative approaches, instead of making rushed decisions in an emergency, reduces stress and leads to a plan that better matches their values. Kidney failure remains a serious, life-limiting condition, but it is not a sudden sentence; with ongoing care, you and your team can often chart a path that preserves comfort, function, and autonomy for as long as possible.

Prevention

How can I prevent kidney failure?

Kidney failure and established chronic kidney disease cannot be reversed, but progression can often be slowed. Protecting the kidney function you still have reduces symptoms, lowers the risk of heart and blood vessel complications, and can delay the need for dialysis or transplant.

Monitoring Kidney Function: Regular blood and urine tests help track estimated glomerular filtration rate (eGFR), creatinine, and protein in the urine. Trending these values over time shows whether your kidneys are stable, slowly declining, or deteriorating more quickly, and allows your provider to adjust treatment before a crisis develops.
Managing Blood Sugar In Diabetes: Keeping blood glucose as close to target as safely possible reduces the damage that high glucose levels cause to the tiny blood vessels in the kidneys. This usually involves a combination of medication, structured eating patterns, and regular home glucose or continuous glucose monitoring, coordinated with your diabetes and kidney teams.
Controlling Blood Pressure: Maintaining blood pressure in the range recommended for you protects both the heart and the kidneys. This usually requires daily medication, moderation of salt intake, and monitoring of weight and activity levels. Even modest improvements in blood pressure control can slow the progression of kidney damage.
Avoiding Tobacco Products: Smoking and other forms of tobacco use constrict blood vessels, reduce kidney blood flow, and accelerate scarring. Stopping tobacco use reduces vascular stress and enhances the efficacy of other kidney-protective strategies, even when other risk factors cannot be fully eliminated.
Adjusting Diet and Minerals: Individuals with kidney disease are often advised to limit sodium intake and, in more advanced stages, to adjust potassium and phosphorus intake. Tailoring these changes to your stage of disease and your lab values can reduce swelling, help control blood pressure, and protect bones and blood vessels. Working with a renal dietitian can make these adjustments more practical and sustainable.
Keeping Scheduled Appointments: Regular visits with your primary care clinician and nephrologist enable ongoing medication adjustments, early recognition of complications such as anemia or bone disease, and timely planning for dialysis or transplantation, if needed. Skipping visits increases the likelihood that problems will be detected only when they are already severe.

Some people develop kidney failure despite careful attention to these measures because of inherited conditions, complex autoimmune diseases, or severe acute injuries that cannot be fully reversed. In such situations, the same strategies remain important because they support other organs, improve stamina, and can make dialysis or transplantation safer and more effective.

Living With

When should I see a healthcare provider?

You should contact a healthcare provider if you have known risk factors for kidney disease or notice persistent changes that could signal declining kidney function. This includes long-standing high blood pressure, diabetes, or heart disease; a family history of kidney disease; or a past episode of acute kidney injury. New or worsening symptoms such as changes in how often or how much you urinate, swelling in the legs or face, ongoing nausea or vomiting, unexplained fatigue or “brain fog,” or flank pain are reasons to be evaluated. Regular users of nonsteroidal anti-inflammatory drugs (NSAIDs) or other pain medicines should also be reviewed periodically, especially if they have other risk factors, because these drugs can stress the kidneys over time.

Additional Common Questions

When is it time for hospice if I have kidney failure?

Hospice care focuses on comfort, symptom control, and support when a condition is no longer being treated with life-prolonging interventions or when those interventions are no longer aligned with a person’s goals. In kidney failure, hospice is typically considered when dialysis or transplant is not possible, is no longer effective at controlling symptoms, or has been chosen against because the burdens outweigh the benefits for that person. Signs that it may be time to discuss hospice include frequent hospitalizations, increasing weakness and symptoms despite treatment, difficulty tolerating dialysis sessions, and a desire to focus on comfort at home rather than ongoing intensive interventions. Your nephrologist, primary care clinician, and palliative care team can help you and your family understand what to expect with and without dialysis and decide whether hospice matches your priorities for the time ahead.

The IWBCA provides the information and materials on this site for educational and informational purposes only. The content is not a substitute for professional medical evaluation, diagnosis, or treatment. Always consult your physician or another qualified healthcare provider regarding any questions you may have about a medical condition, diagnosis, or course of treatment. Do not disregard, delay, or alter medical advice based on information obtained from this site. If you believe you are experiencing a medical emergency, call 911 or your local emergency services immediately.