Patients on dialysis are NOT healthy.
This is the definition of an ASA IV.
ASA IV A patient with severe systemic disease that is a constant threat to life.
If you need a machine to get rid of K every two days, that is severe systemic disease - and constantly a threat...because the machine is a machine.
People (not the ASA) have tried to use the classification system for things it was never meant for. That doesn't mean it is a bad classification...it just means people use it wrong.
Please note - ASA classification says nothing about functional status, how well a disease process is managed, how well the other systems are working, etc.
Based on the very simple definition, someone could be a marathon runner, the best max VO2 in the word, be pescatarian (best mortality rates), and have known large aneurysms systemically that are very tenuous and could rupture at any second - that would be an ASA IV.