Stage 4 chronic kidney disease (CKD) involves moderate to severe kidney damage, and low remaining kidney function. Stage 4 kidney disease is the final stage before kidney failure, which means that it’s time to start exploring your options and preparing for the next steps once your kidneys stop working. 

At stage 4 chronic kidney disease, your eGFR is between 15 and 29, which means you are in an advanced stage of kidney disease, with moderate to severe damage to your kidneys. As your kidney function worsens, more waste products will build up in your blood, which causes uremia, one of the major signs of kidney failure.

Moreover, this stage of kidney disease predisposes you to related complications and conditions, which include:

• High blood pressure
• Diabetes
• Anemia (shortage of red blood cells)
• Bone disease
• Heart disease
• Other cardiovascular diseases

Much like the symptoms that begin to present themselves in stage 3 CKD, you may experience:

• Back pain
• Swelling (edema) in your hands and feet
• Changes in urination (foamy; dark orange, brown, tea-colored, or red if bloody; and urinating less or more than normal)

You may experience back pain as a symptom of kidney disease. (This photo is from Freepik.)

Additional symptoms of stage 4 kidney disease include:

• Fatigue
• Fluid retention
• Shortness of breath
• Sleep issues (due to muscle cramps or restless legs)
• Nausea and/or vomiting
• Changes in taste (metallic taste in mouth)
• Bad breath (caused by urea buildup in the blood)
• Loss of appetite
• Difficulty concentrating on everyday tasks
• Nerve problems (numbness or tingling in toes or fingers)

If you are not already seeing a nephrologist (kidney doctor), you will need to start seeing one regularly during stage 4. They will create a personalized treatment plan for you that will also include how often you need to get your kidneys checked. To confirm your diagnosis, the nephrologist will order blood and urine tests to check your levels of:

• Creatinine. Creatinine is a waste product of protein and muscle metabolism. Your kidneys should filter creatinine out of your bloodstream. When they don’t your creatinine level is higher.
• Hemoglobin. Hemoglobin carries oxygen to your tissues and organs, and transports carbon dioxide away from them. Greater kidney damage results in lower hemoglobin levels.
• Calcium and phosphorus. Calcium and phosphorus are minerals that need to be in balance in your body. Damaged kidneys don’t remove excess phosphorus. Phosphorus buildup is linked to less calcium in your blood.  

The goal of your nephrologist is to encourage kidney function for as long as possible. Stage 4 kidney disease cannot be reversed, but you can take steps to help slow disease progression. For people with CKD, it’s critical to control any other underlying medical issues you may have, and prevent or treat CKD complications. Your nephrologist is likely to:

• Monitor any CKD-related conditions, like high blood pressure, diabetes, and heart disease, 
• Prescribe blood pressure medications, such as ACE inhibitors and ARBs, if you’re not already taking them, and
• Refer you to a renal dietitian who can help you develop a kidney-friendly diet to best support your unique needs. 

Talk to your doctor about creating an exercise plan that fits your personalized needs as a stage 4 CKD patient. (This image is by @Racool_studio on Freepik.)

In addition to following a kidney-healthy diet and the high blood pressure medications above, your doctor will likely advise you to make lifestyle modifications, such as:

• Maintain a healthy weight, including losing weight if you are overweight.
• Cut down on the amount of sodium (salt) in your diet.
• Monitor your blood sugar, follow your diet plan, and take your medications as prescribed if you have diabetes or heart disease.
• Exercise regularly, as possible.
• Quit smoking, or don’t start. 

Your renal dietitian can help you craft a healthy and tasty diet for your specific needs and preferences.

As previously stated, stage 4 CKD is not kidney failure. Stage 4 is the last stage before kidney failure. Kidney failure occurs in stage 5 CKD, which is also known as end-stage kidney disease (ESKD) or end-stage renal disease (ESRD).

Prognosis varies by person and is affected by any related medical conditions and what treatments you have done or are doing. Your doctor can give you a more accurate idea of your unique prognosis and what to expect moving forward.

Stage 4 CKD is a good time to start considering your options and next steps once your kidneys stop functioning. Currently, these options include:

• Dialysis
• Kidney transplant
• Neither

While there is no cure for either kidney disease or kidney failure, proper treatment, compassionate support, and customized lifestyle changes can help you to maintain a good quality of life.