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With chronic kidney disease, the kidneys don’t usually fail all at once. Instead, kidney disease often progresses slowly over a period of years. This is good news because if CKD is caught early, medicines and lifestyle changes may help slow its progress and keep you feeling your best for as long as possible.
To help improve the quality of care for people with kidney disease, the National Kidney Foundation (NKF) created a guideline to help doctors identify each level of kidney disease. The NKF divided kidney disease into five stages. When the doctor knows what stage of kidney disease a person has they can provide the best care, as each stage calls for different tests and treatments.
Glomerular filtration rate (GFR) is the best measure of kidney function. The GFR is the number used to figure out a person’s stage of kidney disease. A math formula using the person’s age, race, gender and their serum creatinine is used to calculate a GFR. A doctor will order a blood test to measure the serum creatinine level. Creatinine is a waste product that comes from muscle activity. When kidneys are working well they remove creatinine from the blood. As kidney function slows, blood levels of creatinine rise.
Below shows the five stages of CKD and GFR for each stage:
Dialysis or a kidney transplant needed in order to maintain health.
A person with Stage 4 CKD has advanced kidney damage with a severe decrease in the 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 that are experienced in Stage 4 include:
At Stage 4 it is necessary to see a nephrologist (a doctor who specializes in treating kidney disease). The nephrologist examines the kidney patient and orders lab tests to gather information to recommend treatment.
People in Stage 4 CKD will usually visit their doctor at least every 3 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.
Those with Stage 4 CKD who will need treatment are told about their choices, which are hemodialysis, peritoneal dialysis or a kidney transplant. For those who choose hemodialysis they will learn about getting a vascular access. The vascular access allows the patient’s blood to travel to and from the dialysis machine at a large volume and high speed so that toxins, waste and extra fluid can be removed from the body. The AV (arteriovenous) fistula and AV graft are created surgically and need a few months or so to mature. The nephrologist will inform their Stage 4 patient about the procedure to have the access placed and the advantages of having an AV fistula in place before beginning dialysis.
Someone 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. For Stage 4 a dietitian will usually recommend eating a healthy diet with reduced amounts of protein to help decrease build up of protein waste. Phosphorus may be limited to help keep blood phosphorus or PTH normal and prevent renal bone disease. Controlling phosphorus may also help preserve existing kidney function. Calcium may be limited if blood levels are too high. Potassium may be restricted in Stage 4 CKD if blood levels are above normal. The dietitian will also take into consideration if the patient has diabetes and provide tips on limiting carbohydrates in their diet. They may also recommend a diet low in sodium for those with high blood pressure or fluid retention. Supplementation with water soluble vitamins may be recommended. Vitamin C may be limited to 100 mg per day from supplements. Nutrients like Vitamin A and some minerals may not be recommended because levels can build up in the blood as kidney function declines. The dietitian may recommend avoiding over the counter dietary supplements unless approved by the nephrologist. It is helpful to work with a registered renal dietitian because as the stages of CKD change, so will the diet.
A healthy diet for stage 4 CKD may recommend:
It is 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.
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 guidelines recommend starting dialysis when kidney function drops to 15% 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.
If you would like to see a doctor who specializes in the care of kidneys, called a nephrologist, you can use DaVita's Find a kidney doctor tool to locate a nephrologist in your area.
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