Stage 4 of Chronic Kidney Disease

A person with stage 4 chronic kidney disease (CKD) has advanced kidney damage with a severe decrease in the glomerular filtration rate (GFR) to 15-30 ml/min. It is likely someone with stage 4 CKD will need dialysis or a kidney transplant in the near future.

As kidney function declines, waste products build up in the blood causing a condition known as uremia. In stage 4, a person is likely to develop complications of kidney disease such as high blood pressure, anemia (a shortage of red blood cells), bone disease, heart disease and other cardiovascular diseases.

Symptoms of stage 4 kidney disease

Symptoms that are experienced in stage 4 include:

• Fatigue
• Fluid retention, swelling (edema) of extremities and shortness of breath
• Urination changes (foamy; dark orange, brown, tea-colored or red if it contains blood; and urinating more or less than normal)
• Kidney pain felt in their back
• Sleep problems due to muscle cramps or restless legs
• Nausea and/or vomiting
• Taste changesa metallic taste in the mouth
• Bad breath due to urea buildup in the blood
• Loss of appetite: People may not feel like eating, and some people report having a metallic taste in their mouth or bad breath.
• Difficulty in concentrating: Having trouble doing everyday things such as balancing a checkbook or focusing on reading the newspaper can occur.
• Nerve problems: Numbness or tingling in the toes or fingers is a symptom of CKD.

Seeing a doctor when you have stage 4 CKD

At stage 4, it’s necessary to see a nephrologist (a doctor who specializes in treating kidney disease). The nephrologist examines the patient and orders lab tests to gather information to recommend treatment.

People in stage 4 CKD will usually visit their doctor at least every three months. Blood tests for creatinine, hemoglobin, calcium and phosphorus levels will be done to see how well the kidneys are working. The doctor will also monitor other conditions such as high blood pressure and diabetes. In addition to helping the patient keep their kidneys working as long as possible, the nephrologist will also help prepare the patient for dialysis or a kidney transplant.

Looking at treatment options when you have stage 4 CKD

Those with stage 4 CKD who will need treatment are told about their choices, including:

1. Hemodialysis: This is a treatment that can be done in a center or in a patient’s home with assistance from a care partner. A dialysis machine removes a small amount of a patient’s blood through a man-made membrane called a dialyzer, or artificial kidney, to clean out toxins that the kidneys can no longer remove. The filtered blood is then returned to the body.
2. Peritoneal dialysis (PD): Unlike hemodialysis, PD is a needle-free treatment and a care partner is not required to to help assist during treatment. PD can be performed at home or at work.
3. Kidney transplant: This is a preferred treatment and does not require as many diet restrictions as those who are on hemodialysis or PD.

Meeting with a dietitian when you have stage 4 CKD

A person in stage 4 may also be referred to a dietitian. Because diet is such an important part of treatment, the dietitian will review a person’s lab work results and recommend a meal plan individualized for their needs. Eating a proper diet can help preserve kidney function and overall health.

Diet and stage 4 CKD

For stage 4 CKD, a healthy diet is likely to consist of:

• Reducing protein consumption to help decrease the buildup of protein waste
• Consuming a some grains, fruits and vegetables (potassium and phosphorus are at normal levels)
• Limiting phosphorus to help PTH levels remain normal, prevent bone disease and even preserve existing kidney function
• Restricting potassium if blood levels are above normal
• Lowering calcium consumption
• Cutting back carbohydrates for those with diabetes
• Decreasing saturated fats to help lower cholesterol
• Lowering sodium for people with hypertension or fluid retention by cutting out processed and pre-packaged foods
• Limiting calcium if blood levels are too high
• Taking water soluble vitamins such as vitamin C (100 mg per day) and vitamin B complex, or completely avoiding over-the-counter dietary supplements (unless approved by the nephrologist)

Medications and stage 4 CKD

It’s recommended that people in stage 4 keep their blood pressure at a healthy level and those with diabetes keep their glucose level under control. Taking all the medicines as prescribed by the doctor may help prolong kidney function.

Managing stage 4 CKD

In addition to eating right and taking prescribed medicines, exercising regularly and not smoking are helpful in maintaining health. Patients should talk to their doctors about an exercise plan. Doctors can also provide tips on how to stop smoking.

The National Kidney Foundation (NKF) guidelines recommend starting dialysis when kidney function drops to 15 percent or less. By doing everything possible to help prolong kidney function and overall health, the goal is to put off dialysis or transplant for as long as possible.