Dialysis and Kidney Transplant

If you or someone you love is approaching kidney failure, you are likely facing one of the harder decisions a family ever makes — and doing it while tired, overwhelmed, and swimming in unfamiliar words. Take a breath. You almost always have more time and more choices than the moment feels like it allows. There is rarely a single "right" answer here; there is the answer that fits your body, your values, and the life you want to keep living. This page walks through the four real paths — hemodialysis, peritoneal dialysis, kidney transplant, and conservative (non-dialysis) care — in plain language, so you can sit down with your kidney doctor as a partner in the decision rather than a passenger. Choosing not to pursue aggressive treatment can be a wise, dignified choice too, and we say so honestly below.

When the Kidneys Fail: Stage 5 and the Signs It's Time
Your Four Choices, Framed Honestly
Hemodialysis, Explained
Peritoneal Dialysis: Using Your Belly's Lining
Kidney Transplant: The Closest Thing to a Cure
Preparing Early: Veins and the Waitlist
Conservative Care: A Legitimate Choice
Living Well: Diet, Work, and Travel
Costs and Coverage in the US
Key Research Papers
Connections

When the Kidneys Fail: Stage 5 and the Signs It's Time

Kidney failure — stage 5 chronic kidney disease, sometimes called end-stage kidney disease (ESKD) or end-stage renal disease (ESRD) — is defined as an eGFR below 15 mL/min/1.73 m². But the number on its own does not decide anything. Plenty of people feel reasonably well at an eGFR of 12 or 13, and the decision to start treatment is guided as much by how you feel as by the lab value. Modern practice is generally to start when symptoms appear rather than at a fixed number, and to plan long before that point arrives.

The symptoms that tend to tip the balance toward starting dialysis (or activating a transplant plan) include:

Fluid you can't get rid of — swelling in the legs and around the eyes, weight climbing from retained water, and especially shortness of breath from fluid backing up into the lungs.
Nausea, vomiting, and a shrinking appetite — often with a metallic taste and unintended weight loss. This build-up of waste is called uremia.
Deep fatigue and mental fog — trouble concentrating, daytime sleepiness, and in severe cases confusion.
Relentless itching and restless, twitchy legs.
Rising potassium on lab tests, which can disturb the heart's rhythm, and stubborn acid build-up (acidosis).

None of these means you have run out of time. They are signals to move a plan you have hopefully already built into action. The worst outcomes happen when kidney failure is discovered as an emergency — a "crash start" on dialysis through a neck catheter in the hospital — rather than through calm, months-ahead planning.

Your Four Choices, Framed Honestly

When the kidneys can no longer keep up, there are four legitimate paths. None is automatically best for everyone.

Hemodialysis (HD) — a machine cleans your blood, either at a dialysis center three times a week or at home more frequently. The most common choice in the US.
Peritoneal dialysis (PD) — you use the natural lining of your own abdomen as a filter, doing exchanges at home, often overnight while you sleep. No needles, no machine pulling your blood.
Kidney transplant — a healthy kidney from a living or deceased donor. It offers the longest survival and the best quality of life for those who are candidates, and can sometimes be done before dialysis is ever needed.
Conservative (non-dialysis) care — also called supportive or comprehensive conservative management. You choose not to do dialysis and instead focus on controlling symptoms, protecting comfort and independence, and living as well as possible for as long as possible. For some older or frail people this is the kindest, most sensible choice, not a "giving up."

Many people also change course over time — starting on PD and later switching to HD, or doing dialysis while waiting for a transplant. These are not one-way doors.

Hemodialysis, Explained

In hemodialysis, your blood is pumped out a little at a time, passed through a filter called a dialyzer (an "artificial kidney" full of thousands of tiny hollow fibers), cleaned of waste and excess fluid, and returned to you. The machine does in a few hours what your kidneys used to do around the clock.

In-center vs. home

In-center hemodialysis is the familiar model: you go to a dialysis clinic three times a week, and each session lasts roughly three-and-a-half to four hours. Trained staff run everything; you sit in a recliner, often reading, napping, or watching a screen. Home hemodialysis is done by you (usually with a trained care partner), typically more often — five to six shorter daytime sessions a week, or longer sessions overnight while you sleep (nocturnal HD). More frequent dialysis more closely mimics natural kidneys: the Frequent Hemodialysis Network trials found that six-times-weekly hemodialysis improved blood pressure control, reduced the size of an enlarged heart, and improved how people felt, though at the cost of more procedures to keep the access working.

The access — and why a fistula is best

To move enough blood, dialysis needs a reliable, high-flow connection to your bloodstream. There are three kinds, and the differences matter enormously for your health:

AV fistula (the gold standard). A surgeon joins an artery to a vein in your arm. Over two to three months the vein thickens and enlarges ("matures") until it can handle the dialysis needles. A fistula uses only your own tissue, so it has the lowest risk of infection and clotting and lasts the longest — often many years. The catchphrase in kidney care is "Fistula First."
AV graft. When your veins are too small or fragile for a fistula, a surgeon connects the artery and vein with a soft synthetic tube. Grafts can be used sooner (a few weeks) but clot and get infected more often than fistulas.
Central venous catheter. A soft tube placed in a large vein in the neck or chest. It works immediately — no waiting to mature — which is why it is used in emergencies. But it carries by far the highest risk of serious bloodstream infection and clotting, so it is meant as a short-term bridge, not a long-term plan. Avoiding a catheter is one of the biggest reasons to plan access surgery months ahead.

What a session feels like

Two needles go into the fistula or graft (numbing cream helps); a catheter needs no needles. During the session most people feel normal — they chat, sleep, or use a phone. Toward the end, some feel washed out, and pulling off too much fluid too fast can cause cramps, nausea, or a drop in blood pressure that leaves you lightheaded. Many people feel tired for a few hours afterward ("dialysis hangover"), which is one reason home and more-frequent schedules appeal to those who want to keep working or stay active.

Peritoneal Dialysis: Using Your Belly's Lining

Peritoneal dialysis skips the machine-and-needles approach entirely. The peritoneum — the thin membrane lining your abdomen — is rich in tiny blood vessels and works as a natural filter. A soft, permanent catheter is placed in your belly (a minor procedure). You run a special sugar-based cleansing fluid (dialysate) in through the catheter, let it sit ("dwell") while waste and extra fluid seep across the membrane into it, then drain it out and replace it. This is called an exchange.

CAPD (continuous ambulatory peritoneal dialysis) is done by hand, usually four exchanges spread across the day, each taking about 30–40 minutes. No machine, so it travels easily.
APD (automated peritoneal dialysis) uses a small bedside machine called a cycler that performs the exchanges automatically overnight while you sleep, leaving your days free.

The upsides: PD is done at home on your schedule, needs no needles, and is gentler on the heart because it cleans you gradually and continuously rather than in big three-times-a-week swings. It tends to preserve whatever natural kidney function you have left for longer, and it makes travel and work much easier. The trade-offs: it demands clean, careful technique because the main risk is peritonitis, an infection of the abdominal lining (treatable, but it means antibiotics and sometimes hospital time). The dialysate contains sugar (dextrose) that your body absorbs, which can nudge up weight and blood sugar. And PD may not work well if you have had extensive abdominal surgeries or scarring. Over the long run, large studies show survival on PD and HD is broadly similar, so the choice often comes down to lifestyle and personal fit rather than one being medically superior.

Kidney Transplant: The Closest Thing to a Cure

A successful transplant is the treatment that comes nearest to restoring normal life. It is not a cure — it trades kidney failure for the lifelong job of protecting a transplanted organ — but for those who are candidates, it offers the longest survival and the best quality of life of any option. In a landmark study, Wolfe and colleagues found that transplant recipients had a roughly 68% lower long-term risk of death than similar patients who stayed on the waiting list on dialysis; earlier work by Port and colleagues showed the same survival advantage.

Living vs. deceased donor

A kidney can come from a living donor (often a relative, spouse, or friend — even an anonymous "altruistic" donor, sometimes through paired-exchange chains that match incompatible pairs) or from a deceased donor. Living-donor kidneys generally start working immediately, are scheduled at a planned time, and last longer on average — commonly around 15–20 years — versus roughly 10–12 years for a deceased-donor kidney. Humans function well with one kidney, and donor safety is carefully protected.

The waitlist and preemptive transplant

In the United States, roughly 90,000 people are waiting for a kidney at any time, and the wait for a deceased-donor organ often runs three to five years or more, depending on blood type and region. That is why the single most important idea in transplantation is timing: a preemptive transplant — getting a new kidney before you ever start dialysis — produces the best results. Time spent on dialysis is, in the words of one influential analysis (Meier-Kriesche and Kaplan), "the strongest modifiable risk factor" for how long a transplant and its recipient survive. You can usually be listed once your eGFR falls to about 20, well before dialysis is needed, so ask about listing early.

Anti-rejection medicine and realistic outcomes

Because your immune system sees the new kidney as foreign, you take immunosuppressant (anti-rejection) medicines for as long as the kidney works — typically a combination such as tacrolimus, mycophenolate, and a low dose of a steroid. Missing doses is the fastest way to lose a transplant. These drugs raise the risk of infections and certain cancers and require regular monitoring, which is a real and lifelong responsibility. Even so, results are excellent: more than 90–95% of transplanted kidneys are still working one year later. A transplant will not last forever, and some people need a second one or return to dialysis — but for the right person it can mean many years of a fuller, freer life.

Preparing Early: Veins and the Waitlist

Almost everything that goes well in kidney failure was set up months or years in advance. Two kinds of preparation matter most, and both must happen before you actually need them.

Protect your veins. A good AV fistula depends on healthy arm veins — and those veins are easily ruined by routine hospital use. If you have advancing kidney disease, ask that blood draws, IVs, and especially PICC lines avoid the veins of your non-dominant forearm, which are the ones a surgeon will want for a fistula. Many patients wear a "Save My Veins" wristband or carry a card. This one simple act of vein preservation can be the difference between starting dialysis with a durable fistula versus a high-risk catheter.

Get on the transplant list early. Referral to a transplant center and the evaluation process take time, and you can be placed on the deceased-donor list once your eGFR is around 20. Starting early lets the "clock" of waiting time begin sooner and opens the door to a preemptive transplant. It also gives you time to explore living donation, which does not depend on the waitlist at all. Early referral to a nephrologist — ideally a year or more before kidney failure — is consistently linked to smoother starts and better outcomes.

Conservative Care: A Legitimate Choice

For some people — particularly those who are older, frail, or living with several serious illnesses — choosing not to do dialysis is a thoughtful, dignified decision, not a failure or a surrender. This path is called conservative kidney management or supportive care, and it is active care, not "doing nothing." A team continues to slow the disease with medication and diet, and works hard to control the symptoms of kidney failure — fluid overload, nausea, itching, breathlessness, and fatigue — while protecting comfort, independence, and time at home.

The honest data support offering this choice. Studies of older adults with kidney failure show that while dialysis usually extends life, the survival advantage can be small — and sometimes disappears — in patients over 75 who also have heart disease or several other conditions (Murtagh and colleagues; Chandna and colleagues; Verberne and colleagues). Just as important, dialysis is demanding: three trips a week to a center, hours in a chair, procedures, hospital stays, and for some a loss of the independence they most want to keep. Conservative care can mean fewer hospital days, more time at home, and a death that is planned for and peaceful. For the right person, living well may matter more than living slightly longer. This is a conversation worth having openly with your family and your kidney and palliative-care teams — and it is always your choice, revisitable at any time.

Living Well: Diet, Work, and Travel

Diet on dialysis is different — sometimes the opposite of the CKD diet. Before dialysis, people are often told to limit protein to ease the kidneys' workload. Once you start dialysis, that flips: dialysis itself removes protein and amino acids, so you generally need more protein, not less — roughly 1.0–1.2 grams per kilogram of body weight per day, and even more on peritoneal dialysis (KDOQI 2020 nutrition guidance). Undernutrition is a bigger danger than excess protein at this stage. At the same time you still have to watch potassium and phosphorus, because failed kidneys can't clear them: high potassium threatens the heart, and high phosphorus pulls calcium from bones and calcifies blood vessels. Most dialysis patients take phosphate binders with meals to trap phosphorus in the gut. Fluid also has to be limited, especially on hemodialysis, where too much between-session fluid strains the heart (peritoneal dialysis is usually more forgiving). A renal dietitian is part of your team — use them.

Work. Many people keep working through dialysis, and home and nocturnal schedules make this far easier by freeing up daytime hours. Employers in the US must make reasonable accommodations, and vocational support is available.

Travel. Dialysis does not have to ground you. Hemodialysis patients can arrange "transient" sessions at a center near their destination (book weeks ahead), and peritoneal dialysis patients can have supplies shipped where they are going or carry them. People on dialysis travel, work, and take vacations — it takes planning, not permission.

Costs and Coverage in the US

Kidney failure holds a unique place in American health policy. Since the 1972 Medicare ESRD amendment, Medicare covers people of almost any age once they reach end-stage kidney disease — one of the only conditions that qualifies you for Medicare regardless of how old you are. In plain terms:

Medicare eligibility generally begins the fourth month of in-center dialysis. It can start the first month if you train for home dialysis (HD or PD), and immediately for a transplant admission.
Medicare helps pay for dialysis, transplant surgery, and follow-up care. Thanks to a 2023 change in the law, it now covers the crucial anti-rejection (immunosuppressant) drugs for the lifetime of the transplant, closing an old gap that once put grafts at risk when coverage ran out.
Medicare typically pays 80% of approved costs, leaving a 20% coinsurance plus premiums and deductibles. Many people cover the rest with a Medigap plan, Medicaid, an employer plan, or a Medicare Advantage plan.
If you have employer group coverage, that plan usually pays first for the initial 30 months, with Medicare secondary during that window.

Over the long run, a transplant is far less expensive than years of dialysis — another reason the system encourages transplantation. Costs are real and paperwork is heavy, so lean on the clinic social worker: helping patients navigate coverage, drug assistance, and transportation benefits is a core part of their job. No one should skip treatment for lack of understanding the coverage they are entitled to.

Key Research Papers

Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. New England Journal of Medicine. 1999;341(23):1725-1730.
Port FK, Wolfe RA, Mauger EA, et al. Comparison of survival probabilities for dialysis patients vs cadaveric renal transplant recipients. JAMA. 1993;270(11):1339-1343.
Meier-Kriesche HU, Kaplan B. Waiting time on dialysis as the strongest modifiable risk factor for renal transplant outcomes: a paired donor kidney analysis. Transplantation. 2002;74(10):1377-1381.
Tonelli M, Wiebe N, Knoll G, et al. Systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes. American Journal of Transplantation. 2011;11(10):2093-2109.
FHN Trial Group; Chertow GM, Levin NW, Beck GJ, et al. In-center hemodialysis six times per week versus three times per week. New England Journal of Medicine. 2010;363(24):2287-2300.
Rocco MV, Lockridge RS, Beck GJ, et al. The effects of frequent nocturnal home hemodialysis: the Frequent Hemodialysis Network Nocturnal Trial. Kidney International. 2011;80(10):1080-1091.
Mehrotra R, Chiu YW, Kalantar-Zadeh K, et al. Similar outcomes with hemodialysis and peritoneal dialysis in patients with end-stage renal disease. Archives of Internal Medicine. 2011;171(2):110-118.
Murtagh FEM, Marsh JE, Donohoe P, et al. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrology Dialysis Transplantation. 2007;22(7):1955-1962.
Chandna SM, Da Silva-Gane M, Marshall C, et al. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrology Dialysis Transplantation. 2011;26(5):1608-1614.
Verberne WR, Geers AB, Jellema WT, et al. Comparative survival among older adults with advanced kidney disease managed conservatively versus with dialysis. Clinical Journal of the American Society of Nephrology. 2016;11(4):633-640.
Robinson BM, Akizawa T, Jager KJ, et al. Factors affecting outcomes in patients reaching end-stage kidney disease worldwide: differences in access to renal replacement therapy, modality use, and haemodialysis practices. The Lancet. 2016;388(10041):294-306.
Ikizler TA, Burrowes JD, Byham-Gray LD, et al. KDOQI clinical practice guideline for nutrition in CKD: 2020 update. American Journal of Kidney Diseases. 2020;76(3 Suppl 1):S1-S107.

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