Uremic Symptoms: Nausea, Itch, and When to Start Dialysis
When Your Body Starts Warning You It’s Failing
You wake up scratching. Not just a little. You’re bleeding from the back of your neck, your arms, your legs. Food tastes like metal. You eat a bite of toast and throw it up. You’ve lost 15 pounds in two months, but your clothes don’t feel looser-just heavier. You’re tired all the time, even after sleeping 10 hours. This isn’t stress. It’s not allergies. It’s not a virus. This is uremia.
Uremia isn’t a disease. It’s your body screaming because your kidneys have stopped working. When kidneys fail, toxins like urea, creatinine, and indoxyl sulfate build up in your blood. These aren’t just numbers on a lab report-they’re what make you nauseous, itchy, confused, and desperate to sleep. And if you ignore them, you risk heart failure, seizures, or death.
Why You Can’t Just ‘Wait It Out’
For decades, doctors told people to wait until they were near death before starting dialysis. That’s not true anymore. In 2020, the IDEAL trial followed over 1,200 patients with kidney failure. One group started dialysis when their eGFR was around 10. The other waited until it dropped to 5-7. Guess what? Neither group lived longer. But the group that waited longer had far fewer symptoms-if they managed them well.
Here’s the catch: if you wait too long and your symptoms spiral, you can’t just snap back. Severe itching ruins sleep for months. Nausea kills your appetite. You lose muscle. Your heart gets strained. By the time you start dialysis, you’re already behind. The goal isn’t to start early just because your numbers look bad. It’s to start before your body breaks down.
The Two Worst Symptoms: Nausea and Itch
Nausea: The Silent Starvation
Up to 68% of people with stage 5 kidney disease report constant nausea. It’s not just morning sickness. It’s a deep, gut-wrenching feeling that makes you avoid food entirely. Studies show this happens when blood urea nitrogen (BUN) hits above 80 mg/dL. But here’s what most doctors don’t tell you: it’s not just urea. Toxins like p-cresyl sulfate and indoxyl sulfate-waste products your kidneys can’t filter-are directly linked to nausea severity. One study found a 0.78 correlation between these toxins and vomiting frequency.
Patients describe it as “swallowing sand” or “tasting blood.” One man on Reddit lost 18 pounds in two months because he couldn’t eat without gagging. His weight dropped so fast his doctor thought he had cancer. He didn’t. He had kidney failure.
Doctors treat this with ondansetron (Zofran), 4mg three times a day. If that doesn’t work, domperidone is an option-but it’s risky. It can mess with your heart rhythm. That’s why some patients get relief only after dialysis starts. Because dialysis removes these toxins. Not just urea. All of them.
Itch: The Invisible Pain
Uremic pruritus-also called CKD-associated pruritus-is the most underreported symptom in kidney disease. Up to 70% of dialysis patients suffer from it. And it’s not just dry skin. It’s a deep, burning, crawling sensation that doesn’t respond to lotion, antihistamines, or even steroids.
It hits at night. It’s worst on your back, arms, and legs. It’s symmetrical. It doesn’t leave a rash. That’s how you know it’s uremic. The International Forum for the Study of Itch says if you’ve had itching for more than six weeks with no visible skin changes, and you’ve ruled out liver disease, thyroid issues, and allergies-you’re dealing with uremic pruritus.
And it’s not just annoying. It’s disabling. A 2022 survey found 64% of patients said itching interfered with daily life. 28% quit their jobs because they couldn’t focus. One woman said she stopped hugging her kids because she was afraid she’d scratch them. Her 5-D Itch Scale score? 18 out of 20. That’s severe.
Doctors now use the 5-D scale to measure it: Duration, Degree, Direction, Disability, Distribution. A score over 12 means you need meds. Over 15? You’re a candidate for dialysis-even if your eGFR is still at 10.
When Exactly Should You Start Dialysis?
There’s no magic number. But here’s what the experts agree on:
- If your eGFR is below 10.5 mL/min/1.73m² and you have refractory nausea (can’t eat, lost 5% body weight in 3 months), start dialysis.
- If your itching score hits 15+ on the 5-D scale, and gabapentin and optimized dialysis didn’t help, start dialysis.
- If you have uremic pericarditis (fluid around the heart), start dialysis immediately. This is an emergency.
- If you’re confused, shaky, or having muscle twitches-those are signs of advanced toxin buildup. Don’t wait.
Some doctors still push for early dialysis at eGFR 12-15. But the data doesn’t show better survival. What it does show? Better quality of life if you wait until symptoms hit-and manage them right.
Here’s the bottom line: dialysis doesn’t cure kidney failure. But it removes the poisons that make you suffer. If your symptoms are controlling your life, you’re ready.
What Happens If You Wait Too Long?
One woman in Florida waited six months after her doctor said she needed dialysis. She thought she’d “get used to it.” She didn’t. She ended up in the ER with fluid in her lungs, a heart rate of 140, and a BUN of 142. She spent three weeks in the hospital. She almost died.
Another man in Texas ignored his itching for a year. He scratched so hard he got infections. He lost two fingers to gangrene. He started dialysis after that. He said, “I wish I’d done it sooner. I lost my hands for nothing.”
Delayed diagnosis is common. A 2022 University of Michigan poll found 41% of patients saw three or more doctors before someone finally said, “Your kidneys are failing.” The average delay? 8.7 months.
That’s why you need to track your symptoms. Write down:
- How often you’re nauseous
- When the itching starts and how bad it is
- If you’re losing weight without trying
- If you’re sleeping less than 5 hours a night
Bring this to your nephrologist. Don’t wait for them to ask.
What Helps Before Dialysis?
There are options-but they’re temporary.
- Optimize dialysis: If you’re already on it, make sure your Kt/V is above 1.4. That means you’re getting enough treatment.
- Gabapentin: Start at 100mg at night. Increase slowly. It helps with itch and nerve pain. But don’t go over 300mg three times a day-your kidneys can’t clear it well.
- Difelikefalin (Korsuva): FDA-approved for itching. Given IV during dialysis. Works in 48 hours. Reduces itch by over 30%.
- Nalfurafine: A newer oral drug. Not yet approved in the U.S., but used in Japan. Reduces itching dramatically.
- Phosphate binders: High phosphate levels make itching worse. Take them with meals.
- Hydration and cool baths: Avoid hot showers. They dry your skin and make itching worse.
But none of this replaces dialysis if your toxins are overwhelming your system. These are bandaids. Dialysis is the cure.
What’s Changing in 2026?
The next big shift? Doctors won’t just look at your eGFR anymore. They’ll look at how you feel.
The 2024 KDIGO guidelines are expected to include patient-reported outcome measures (PROMs). That means if your PROMIS-Itch score is above 15, or your nausea is keeping you from eating, you qualify for dialysis-even if your eGFR is 11.
That’s huge. It means your experience matters more than a lab number. And it’s long overdue.
But disparities still exist. Black patients wait 3.2 months longer than white patients before starting dialysis. Why? Lack of access, mistrust in the system, delayed referrals. That’s not just medical-it’s systemic.
You’re Not Alone
Over 786,000 Americans have end-stage kidney disease. Most of them had nausea. Most of them had itching. Most of them thought they could tough it out.
You don’t have to.
If you’re scratching until you bleed. If you’re throwing up every day. If you’re losing weight and can’t sleep-you’re not being dramatic. You’re not weak. You’re in uremia. And you deserve relief.
Don’t wait for a crisis. Don’t wait for your doctor to say it’s time. If your symptoms are stealing your life, it’s time to talk about dialysis. Not next month. Not next year. Now.
What causes nausea in kidney failure?
Nausea in kidney failure is caused by toxins like urea, p-cresyl sulfate, and indoxyl sulfate building up in the blood because the kidneys can’t filter them out. These toxins trigger the brain’s vomiting center, leading to constant nausea, loss of appetite, and vomiting. Levels above 80 mg/dL for BUN are strongly linked to this symptom.
Why does kidney failure cause itching?
Uremic itching, or CKD-associated pruritus, is caused by a mix of toxins, inflammation, and nerve changes. High levels of phosphate, calcium-phosphorus product, and inflammatory markers like CRP are linked to severe itching. The skin doesn’t always show damage, but the nerves become hypersensitive, leading to intense, unrelenting itch that doesn’t respond to typical treatments.
When should dialysis start based on symptoms?
Dialysis should start when symptoms become unmanageable-even if eGFR is above 5. Key triggers include: persistent nausea causing weight loss of 5% or more in 3 months, severe itching (5-D Itch Scale score >15), uremic pericarditis, confusion, or muscle twitching. The goal is to start before your body breaks down, not after.
Can you treat uremic itching without dialysis?
Yes, temporarily. Options include gabapentin, difelikefalin (Korsuva), nalfurafine, phosphate binders, and optimizing dialysis if already on it. But these only manage symptoms. They don’t remove the toxins causing them. If itching persists despite treatment, dialysis is the only way to address the root cause.
Is it safe to delay dialysis if I feel okay?
No-not if you have symptoms. Feeling “okay” doesn’t mean your body isn’t being damaged. Uremic toxins silently harm your heart, nerves, and bones. Studies show patients who delay dialysis until symptoms are severe have higher hospitalization rates and worse long-term outcomes. The goal is to start before you’re in crisis.
How do I know if my itching is from kidney failure?
Uremic itching is typically: widespread (back, arms, legs), symmetrical, worse at night, and has no visible rash. It lasts more than 6 weeks and doesn’t respond to moisturizers or antihistamines. If you have chronic kidney disease and this pattern, it’s likely uremic. A 5-D Itch Scale score above 12 confirms severe pruritus requiring treatment.
What’s the difference between early and late dialysis initiation?
Early dialysis starts when eGFR is 10-14. Late starts when eGFR is 5-7. The IDEAL trial showed no difference in survival. But late starters had better quality of life-because they avoided dialysis until symptoms forced it. The key is managing symptoms well until then. Starting early doesn’t help you live longer-it just means you spend more time on dialysis.
I've been on dialysis for 3 years now. The itching was the worst part. No lotion, no antihistamines, nothing. It felt like ants crawling under my skin 24/7. Started dialysis when my 5-D score hit 17. Within two weeks, it was like a switch flipped. I slept through the night for the first time in 18 months. Don't wait until you're bleeding. Talk to your nephrologist now.
Bro this is so real. My dad went through this. He ignored the itch for a year. Thought it was dry skin. Ended up in ICU with fluid in lungs. Now he says if he could go back he’d start dialysis the day the doc said ‘your kidneys are failing’. Don’t be like him. Listen to your body.
This post is a masterclass in patient-centered care. The shift from eGFR obsession to symptom-based initiation is long overdue. I’m a nurse in a nephrology clinic, and I’ve seen too many patients suffer needlessly because we prioritized numbers over lived experience. The 2026 PROMs integration will be a game-changer - if we can fix access disparities first.
So let me get this straight. You’re telling me I should get a life-saving treatment because I can’t stop scratching? Wow. Never would’ve guessed. 😒
It is imperative to underscore the gravity of delayed dialysis initiation. The physiological toll of uremic toxin accumulation is not merely symptomatic - it is systemic, insidious, and often irreversible. I implore all individuals with stage 5 CKD to prioritize preemptive intervention, not merely for survival, but for dignity.
Ugh. Another post telling people they’re weak if they don’t jump on dialysis. My cousin did it early and now she’s on it 4x a week, barely leaves the house. She’s miserable. Maybe people should just chill and live their lives. Not everything needs a medical fix.
Actually, the IDEAL trial showed no survival benefit, but it also showed that early starters had higher rates of depression and social isolation. Dialysis is a massive lifestyle disruption. Maybe we should stop treating patients like machines that need to be ‘optimized’ and start treating them like humans who have lives outside of labs.
I just wanted to say thank you for writing this. My mom had all these symptoms and we thought it was just aging. We didn’t connect the dots until she collapsed. This post would’ve saved us months of fear and confusion. I’m sharing it with everyone I know.
I’ve worked in renal care for 22 years. I’ve seen the fear in patients’ eyes when they’re told they need dialysis. But I’ve also seen the relief when they finally get it - the way their skin stops cracking, the way they eat again, the way they hug their grandkids without fear. This isn’t about numbers. It’s about reclaiming your humanity.
I just started dialysis last month after 14 months of itching so bad I wore gloves to bed. Gabapentin helped a little but nothing compared to dialysis. My hands stopped bleeding. I can taste food again. I didn’t realize how much I’d lost until I got it back. If you’re reading this and you’re suffering - please talk to your doctor. You don’t have to live like this.
People like you are why healthcare is broken. You’re scaring folks into getting dialysis because you think you know better than their doctors. Some of us just want to live without needles in our arms. Maybe your body’s fine - you just don’t like the idea of it failing.
The reference to the 2024 KDIGO guidelines is misleading. The draft does not mandate PROMs as a primary criterion for dialysis initiation - it merely recommends their inclusion in shared decision-making. This post dangerously oversimplifies a nuanced clinical framework. Please consult primary literature before disseminating medical advice.
Honestly? I think people who wait are just lazy. If you’re itching so bad you’re bleeding, you’re not ‘trying to tough it out’ - you’re avoiding responsibility. You knew something was wrong for months. You saw three doctors. You ignored the signs. Now you’re surprised you’re sick? Wake up. This isn’t a tragedy - it’s a consequence.
The real issue isn’t dialysis timing - it’s the fact that nephrologists still don’t understand pruritus. Difelikefalin is only approved for dialysis patients. What about pre-dialysis? Why isn’t there an oral version? Why is this still a second-tier symptom? The system is broken. We’re treating the numbers, not the person.