Why has a patient with stage renal disease (end-stage renal disease) stopped producing urine after declining dialysis treatment?

Understanding Decreased Urination in End-Stage Renal Disease

When a patient with end-stage renal disease stops producing urine, it is a direct result of their kidneys losing the ability to filter blood and produce urine, which is why dialysis becomes medically necessary to remove waste products and excess fluid from the body.

Why Urine Production Decreases in ESRD

The progression of kidney disease follows a predictable pattern that eventually leads to decreased or absent urine output:

1. Loss of Filtering Capacity:

   • As kidney disease progresses to end-stage, the nephrons (filtering units) become increasingly damaged
   • The glomerular filtration rate (GFR) falls below 15 mL/min/1.73 m² in end-stage renal disease 1
   • At this point, the kidneys can no longer effectively filter waste products from the blood

2. Accumulation of Waste Products:

   • Without adequate filtration, waste products like urea and creatinine build up in the bloodstream
   • These toxins can cause symptoms of uremia including nausea, fatigue, and confusion
   • The body can no longer maintain proper fluid balance without functioning kidneys

3. Fluid Management Issues:

   • Without urine production, the body cannot eliminate excess fluid
   • This leads to fluid overload, causing swelling, shortness of breath, and potentially dangerous heart conditions

Why Dialysis Is Recommended

Dialysis becomes necessary when the kidneys can no longer perform their essential functions:

• Waste Removal: Dialysis removes toxins that would otherwise build up to dangerous levels 1
• Fluid Balance: Helps remove excess fluid that the kidneys can no longer eliminate
• Electrolyte Balance: Maintains proper levels of potassium, sodium, and other electrolytes
• Acid-Base Balance: Helps correct metabolic acidosis that occurs with kidney failure

Consequences of Declining Dialysis

When a patient declines dialysis, as in this case, they should understand:

• Progressive Symptoms: Uremic symptoms will worsen over time
• Fluid Overload: Without urine output or dialysis, fluid will accumulate in the body
• Limited Survival: Without kidney function or dialysis, survival is typically limited to days or weeks 2
• Quality of Life Impact: Increasing symptoms will affect comfort and function

Addressing Family Concerns About Lack of Urination

It's important to help the family understand:

• Normal Disease Progression: The lack of urine is not unexpected but represents the natural course of end-stage kidney disease
• Not Just About Volume: Even if some urine is produced, it's not effectively removing toxins
• Comfort Focus: Without dialysis, care should focus on symptom management and comfort 2
• Palliative Options: Medications can help manage symptoms like nausea, itching, and pain that may develop 2

Supporting the Patient and Family

For families struggling with a loved one's decision to decline dialysis:

• Ensure they understand this is a natural progression of kidney disease
• Explain that lack of urination reflects the kidneys' inability to function, not dehydration
• Discuss palliative care options to manage symptoms and maintain comfort
• Provide emotional support and counseling resources for both patient and family
• Respect the patient's autonomous decision while ensuring it was made with full understanding

Remember that a palliative approach is a reasonable alternative to dialysis for some patients, particularly those with limited life expectancy or severe comorbid conditions 3.