What Is Stage 4 Kidney Disease?

Kidney disease refers to a chronic (long-term) disease of the kidneys that has been occurring for at least three months. There are five stages of kidney disease—and during stage 4, your kidneys are experiencing severe damage. But, it's important to note that they are still functioning at some capacity and these organs have not yet entered kidney failure.

Stage 4 kidney disease is worse than stage 3, which occurs when you have moderate kidney damage. This stage is also one step away from stage 5 kidney disease, in which true kidney failure happens. About 0.4% of adults in the U.S. have stage 4 kidney disease.

By the time you develop stage 4 kidney disease, you may start to experience some symptoms such as swelling in your legs. However, more serious symptoms don't start occurring until your condition progresses to stage 5.

It's worth noting that being in stage 4 doesn't require you to be on dialysis—a type of treatment that helps replace your kidney function by removing excess water and toxins from your blood. However, your provider may help you start preparing for this treatment or the need for a kidney transplant when you reach stage 4 kidney disease. 

Symptoms

Early on, kidney disease often doesn’t cause any symptoms. Typically, the first three stages of kidney disease cause minimal symptoms or no symptoms at all. In fact, you might not even know you have kidney disease until your condition has progressed.

In stage 4, it's more common for you to start experiencing symptoms. This happens because your kidneys aren't able to get rid of excess fluid and toxins through your urine. Additionally, your body may not be making enough of a hormone called erythropoietin, which is important for producing the red blood cells that your body needs.

As a result, you may begin to experience the following symptoms:

• Swollen ankles and legs
• Puffy eyes
• Anemia
• Fatigue
• Muscle cramps
• Poor appetite
• Nausea and vomiting
• Unintentional weight loss
• Difficulty sleeping
• Itchy skin
• A metallic taste in your mouth
• Bone or joint pain

Keep in mind: not everyone experiences all of these symptoms during stage 4 disease and the symptoms might not always be severe. However, by the time a person develops stage 5 disease, these symptoms start to worsen.

Causes

A variety of causes can lead to severe kidney damage and increase your risk of entering stage 4 kidney disease. These include:

• Diabetes—the leading cause of chronic kidney disease
• High blood pressure
• Kidney infections
• Damage from medications
• Genetic kidney diseases, such as Alport syndrome or polycystic kidney disease
• Autoimmune disorders that affect the kidneys, like lupus
• Vasculitis
• Congenital (or, present at birth) kidney malformations
  

Risk Factors

You may also be at an increased risk of developing kidney disease if you:

• Eat a diet that is high in sodium (salt) or protein
• Smoke tobacco
• Live a sedentary lifestyle
• Do not get enough sleep
• Have a family history of kidney disease

Diagnosis

If you have a family history of kidney disease, a personal history of recurrent kidney infections, or are experiencing symptoms of kidney disease, it's essential to see your healthcare provider for proper testing and diagnosis. During your appointment, your healthcare provider will ask about your medical history, learn about your symptoms, understand your lifestyle habits, and perform a physical exam.

Generally, most people who have stage 4 kidney disease already know that they have chronic kidney disease. But, if you are experiencing symptoms and don't have a diagnosis, it's important to talk to your provider about how you're feeling so they can order the right tests to learn more about your condition.

eGFR

The most common test that healthcare providers order if they suspect kidney disease is an estimated glomerular filtration rate (eGFR) blood test. This test can help your provider diagnose you with the condition and assess what stage of kidney disease you are currently in.

With this test, your healthcare provider will use a small sample of your blood to see how quickly and effectively your glomeruli are working. Your glomeruli are the tiny components in your kidneys that filter toxins and fluids out of the blood. Everyone's eGFR can vary on factors like sex and age. However, most people with healthy, functioning kidneys have an eGFR of 90 millimeters per minute (mL/min).

By the time you are in stage 4 kidney disease, your eGFR has significantly dropped. The following table shows the ranges of eGFR measurements based on which stage of kidney disease you are in:

Additional Tests

While the eGFR test is often the most important, your healthcare provider can also order other tests to learn more about your condition, including:

• Urine albumin-creatine ratio (uACR): Measures protein levels in your urine to assess kidney function
• Complete blood count test: Checks for the presence of related conditions, like anemia or diabetes
• Metabolic panel blood tests: Assesses the balance of your body's fluids and electrolytes to better understand your overall liver and kidney health
• Vitamin D and parathyroid hormone tests: Helps your provider look for the presence of abnormalities in your bones
• Electrocardiogram (ECG/EKG): Looks for heart rhythm problems, which can be a complication of kidney disease

Treatment

Unfortunately, treatment can't reverse damage to your kidneys that occurs during stage 4 kidney disease. But, getting treatment is still essential to slow the progression of your condition and prevent your risk of developing complications. Some treatments may also somewhat help reduce symptoms of stage 4 kidney disease, like ankle swelling or anemia.

Your exact treatment plan will vary on the severity of your condition and the symptoms you're experiencing. Your provider may suggest a combination of treatments, including medication, lifestyle changes, and preparation for kidney failure.

Medications

Common medications for kidney disease generally include:

• Statin drugs like Lipitor (atorvastatin) to reduce the risk of heart complications
• Drugs to lower your blood pressure, such as ACE inhibitors like Capoten (captopril)
• Medications to help your body regulate electrolytes and blood acidity, like sodium bicarbonate or potassium binders
• Iron pills if you have anemia
• Insulin if you have diabetes

Lifestyle Changes

Managing your lifestyle is an important part of treatment when you live with kidney disease. Your healthcare provider may recommend the following:

• Move your body or participate in light to moderate physical activity throughout the week
• Stick to a sleep schedule to ensure you're getting enough rest
• Eat foods that are low in sodium (salt) and moderate in potassium and protein
• Practice stress management techniques such as meditation, yoga, or doing hobbies you enjoy to relieve tension and support your immune system functioning

Preparation for Dialysis or Transplant

Some people with stage 4 kidney disease may also need to prepare for dialysis. Not everyone with stage 4 disease eventually reaches stage 5 kidney disease (or, kidney failure). But those who do will likely need dialysis if their condition progresses.

Before you receive long-term dialysis, you’ll need to have a surgical procedure to prepare the dialysis site—or the part of your body that you will be receiving dialysis in. Depending on the type of dialysis you and your healthcare provider decide is best for you, your dialysis site might be near your belly button or on your forearm.

Healthcare providers don't advise starting dialysis before it’s truly needed. However, because these surgeries take a while to heal, it might make sense for some people with stage 4 disease to have the surgical procedure, especially if it’s clear they will eventually need to start dialysis.

Some people with stage 4 kidney disease might also qualify for a kidney transplant as an alternative to dialysis. This procedure is sometimes completed before a person reaches true kidney failure. The transplant process can take a while, so it may make sense to get medically evaluated and see if a transplant might be a good option for you.

How to Prevent Kidney Disease Progression

If you already have kidney disease, you might not be able to keep it from progressing. However, you might be able to take steps to help it progress more slowly. These steps include: 

• Avoid any medications that are potentially toxic to the kidneys, like Advil (ibuprofen)
• Reduce your tobacco intake or quit smoking
• Work with your healthcare provider to manage other medical conditions related to kidney disease, like diabetes or high blood pressure

Related Conditions

People with chronic kidney disease have an increased risk of developing:

• Heart disease
• Heart attack
• Stroke

This risk may be greater for people who have late-stage kidney disease, such as stage 4 or stage 5. Underlying risk factors, like high blood pressure, diabetes, and smoking, might increase the risk of experiencing both kidney and heart-related conditions.

Living With Stage 4 Kidney Disease

Receiving a diagnosis for kidney disease can feel scary and challenging. It's important to note that however you are feeling is valid. It's also worth noting that you do have options for treatment and getting the right support can help you better manage your condition.

Living with stage 4 kidney disease may mean that you have to make some changes, like which foods you're eating or how much movement you're doing. During stage 4, you may also start to experience symptoms that you didn't have while in earlier stages, which may also be harder to get used to. Fortunately, your healthcare provider can help you understand your treatment options and figure out how to prepare for future treatments, such as dialysis or a kidney transplant.

Keep in mind: it's often helpful to start the planning process for treatment early on. While undergoing treatment (whether now or for stage 5 kidney disease) can feel difficult, getting the care you need can help you slow the progression of your condition and prevent your risk of developing more serious complications.

It’s true that people with chronic kidney disease tend not to live as long as people without the condition. However, many people successfully manage their condition for years by working closely with their healthcare team and seeking support from their loved ones.