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.

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, potassium, 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.

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.

Even if you get treatment in stage 4 and are careful about your health, your kidneys may still fail. Kidney failure happens when:

  • 85-90% of kidney function is gone
  • GFR falls below 15
  • Kidneys don’t work well enough to keep you alive

There is no cure for kidney failure, but with treatment it is possible to live a long, fulfilling life. Having kidney failure is not a death sentence. People with kidney failure live active lives and continue to do the things they love.

Treatments for Kidney Failure

The two treatments for kidney failure are kidney transplantation and dialysis. Two different types of dialysis can be done – hemodialysis and peritoneal dialysis.

  • Kidney Transplantation. This is an operation that places a healthy kidney into your body. The kidney can come from someone who has died or from a living donor. A new kidney will usually function immediately. You will need special medicines to prevent your body from rejecting the new kidney. If rejection happens, dialysis is needed and you can consider a second transplant. A kidney transplant is a treatment, not a cure. Kidney transplant recipients still have chronic kidney disease, and you may still need some of the other medicines you took before the transplant.
  • Hemodialysis (HD). Hemodialysis is a treatment that removes wastes and extra fluid from your blood. It can be done at home (“home hemodialysis”) or in a dialysis center. During hemodialysis, your blood is pumped through soft tubes to a dialysis machine where it goes through a special filter called a dialyzer (also called an artificial kidney). As your blood is filtered, it is returned to your blood stream. Only a small amount of blood is out of your body at any time. In-center treatment time is 3-5 hours, 3 times a week. People who do home hemodialysis have more flexibility about how often it can be done. If done daily, treatment time would be 1½ to 2 hours. You will need an access into the bloodstream for placing needles needed for hemodialysis. Types of access include:
    • Fistula. A fistula is the recommended choice for an access. You will need a minor operation to create a fistula. It is made by joining an artery to a nearby vein under your skin to make a bigger blood vessel. This type of access is preferred because it has fewer problems and lasts longer. However, some people may not be able to have a fistula because of their physical condition. Sometimes, it may be possible to switch to a fistula from another type of access. If you do not have a fistula, ask your dialysis care team if a switch would be possible.fistula-diagram
    • Graft. If your blood vessels are not suitable for a fistula, a graft may be used. This involves joining an artery and a nearby vein with a small, soft tube made of synthetic material. The graft is entirely beneath your skin. You will need a minor operation to create a graft.
    • Catheter. The third type of access, called a catheter, is inserted into a large vein in your neck or chest. The ends of the tubes sit on your skin outside your body. This type of access is generally used when you need dialysis for a short period of time. Catheters are used as a permanent access when a fistula or a graft cannot be placed.catheter-tubes-diagram

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 changes such as a metallic taste in the mouth
  • Bad breath due to urea buildup in the blood
  • Loss of appetite: People may not feel like eating due to nausea or other symptoms caused by waste buildup in the blood
  • 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.

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 in the blood
  • Limiting whole grains, legumes, nuts and certain fruits and vegetables if potassium and phosphorus are above normal levels
  • Limiting foods that contain phosphorus, especially processed foods with phosphorus additives, to help PTH levels remain normal, prevent bone disease and even preserve existing kidney function
  • Restricting high potassium foods if blood levels are above normal
  • Balancing carbohydrates for those with diabetes
  • Decreasing saturated fats to help manage 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 (60 to 100 mg per day) and vitamin B complex
  • Completely avoiding over-the-counter dietary supplements (unless approved by the nephrologist)

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