Medically Reviewed and Compiled by Dr. Adam N. Khan, MD.
What Stage 4 Kidney Disease Means
Stage 4 kidney disease is an advanced form of chronic kidney disease. At this point, the kidneys have lost most of their function, and waste begins to build up quickly. Lab values show an eGFR between 15 and 29. Symptoms are stronger, complications form faster, and patients often need close monitoring.
This stage does not mean the kidneys have failed yet, but it does mean most people will need planning for dialysis or a transplant in the near future.
Causes
Long-term diseases
• Diabetes
• High blood pressure
• Glomerulonephritis
• Polycystic kidney disease
Less common causes
• Frequent kidney infections
• Autoimmune disease
• Long-term NSAID use
Kidney Disease Symptoms at Stage 4
These symptoms often appear together because the kidneys lose their ability to filter waste, control fluid, and balance hormones.
Fatigue and weakness
Low hemoglobin and toxin buildup drain energy.
Swelling
Extra fluid collects in the legs, face, and hands.
Shortness of breath
Fluid retention can affect the lungs or cause anemia-related breathlessness.
Nausea and vomiting
Waste products build up in the bloodstream.
Trouble concentrating
Poor filtering affects brain function.
Loss of appetite
Changes in taste, nausea, and high urea levels reduce hunger.
Muscle cramps
Electrolyte imbalance is common.
Common Complications
Severe anemia
Low erythropoietin levels affect red blood cell production.
Bone and mineral disorders
Calcium, phosphorus, and vitamin D spiral out of balance.
High potassium
Can trigger dangerous heart rhythm problems.
High blood pressure
Worsens kidney damage in a cycle.
Fluid overload
Leads to swelling, chest discomfort, and heart strain.
Diagnosis
Doctors combine symptoms, labs, and imaging to confirm stage 4.
Blood tests
• eGFR
• Creatinine
• BUN
• Potassium
• Calcium
• Phosphorus
Urine testing
Checks for protein and structural problems.
Ultrasound
Shows kidney size, scarring, or cysts.
Other tests
• PTH levels
• Vitamin D
• Hemoglobin
Treatment Overview
The goal is slowing damage, controlling symptoms, and preparing for kidney failure.
Medical Treatment
• Blood pressure control
• Diabetes management
• Medicines for phosphorus, anemia, and potassium
• Diuretics for fluid overload
• Sodium bicarbonate for acidosis
• Antibiotics for infections
Nutrition and lifestyle
• Low sodium
• Low phosphorus
• Moderate protein
• Careful potassium intake
• No NSAIDs
• Daily hydration monitoring
Planning Ahead
• Dialysis education
• Access placement for hemodialysis
• Transplant evaluation
• Vaccinations (hepatitis B, flu, pneumococcal)
Unique Clinical Takeaways
This section gives deeper insights that patients often miss and many general articles do not cover.
1. Symptom Intensity Does Not Always Match Disease Severity
Some patients with eGFR near 20 feel “fine,” while others with eGFR near 28 feel extremely sick. This mismatch happens because toxin buildup varies person to person. A mild-looking patient can have severe metabolic problems on labs. Clinicians rely more on lab trends than symptoms for decisions about dialysis planning.
2. The Transition From Stage 3 to Stage 4 Often Reveals Hidden Disorders
Many people are first diagnosed with:
• Secondary hyperparathyroidism
• Metabolic acidosis
• Subclinical fluid overload
• Resistant hypertension
These issues remain silent until the kidneys drop under 30 percent function. Detecting them early prevents hospitalization and speeds up transplant referrals.
3. Hospitalization Risk Rises for Non-Kidney Reasons
Stage 4 CKD increases vulnerability to:
• Infections
• Heart failure
• Medication toxicity
• Electrolyte disturbances after simple dehydration
• Sudden potassium spikes after minor diet mistakes
Most problems that send patients to the hospital at this stage are not caused by the kidneys themselves but by the kidneys’ reduced reserve. This is why patients need tighter fluid control, medication review, and fast treatment for even mild infections.
Living With Stage 4 Kidney Disease
Daily steps
• Track blood pressure
• Limit salt
• Check body weight every morning
• Take medicines on time
• Avoid dehydration
• Follow nephrology appointments closely
What to ask your doctor
• “Should I start dialysis education now?”
• “Do I qualify for transplant evaluation?”
• “Is my potassium stable?”
• “Do I need phosphate binders yet?”
When Stage 4 Becomes Stage 5
Stage 5 begins when eGFR falls below 15. Signs that the kidneys are approaching failure include:
• Uncontrolled vomiting
• Breathlessness even at rest
• Confusion
• Severe swelling
• Very low appetite
This is usually when dialysis begins.
References and Citations
- National Kidney Foundation – Chronic Kidney Disease stages and patient management.
- Mayo Clinic – Chronic Kidney Disease overview and symptoms.
- American Society of Nephrology – Clinical practice standards for CKD complications.
- Kidney Disease: Improving Global Outcomes (KDIGO) guidelines.
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) – CKD clinical definitions and treatment guidance.
Disclaimer
This article is for education only. It does not replace medical advice, diagnosis, or treatment. Always speak with your doctor for personalized care.