Guide to Managing Stage 4 Chronic Kidney Disease

Guide to Managing Stage 4 Chronic Kidney Disease

feels like learning a whole new language while the plane is already in the air.* eGFR, creatinine, phosphate binders, “renal diet”… it was a lot.

If you’re reading this with Stage 4 CKD—or you’re caring for someone who is—you’re not alone, and you’re not powerless. Stage 4 is serious, but it’s also a window of time where smart decisions can slow the slide toward kidney failure and help you feel a whole lot better day‑to‑day.

I’ll walk you through what I’ve learned supporting patients and family over the years, along with what the science actually says, not just what sounds nice on a wellness poster.

What Stage 4 Chronic Kidney Disease Actually Means

When I first saw “Stage 4” on a lab report, my brain instantly translated it as “end.” That’s not quite accurate.

Stage 4 CKD usually means your eGFR (estimated glomerular filtration rate) is between 15 and 29 mL/min/1.73 m². Healthy is around 90+.

Put simply: your kidneys are working at roughly 15–29% of normal capacity.

At this point, you’re at high risk of:

• Progressing to Stage 5 / kidney failure
• Needing dialysis or a transplant
• Complications like anemia, bone disease, high blood pressure, and heart problems

In my experience, the most helpful mindset shift is this: Stage 4 is not the end; it’s the planning stage. This is when you:

• Tighten up blood pressure and blood sugar control
• Adjust diet more precisely
• Prepare (not panic) about dialysis or transplant options
• Get your team and systems in place so you’re not scrambling later

The Core Goal: Slow Progression and Protect What’s Left

When I tested different explanations with families, the one that clicked most was this: Your kidneys are like employees who are exhausted and short-staffed. Your job is to reduce their workload and prevent further damage.

The main levers we have are:

1. Blood Pressure: The Big One

High blood pressure is like a pressure washer aimed at delicate kidney filters.

Most guidelines (like KDIGO and the American Heart Association) recommend aiming for:

• <130/80 mmHg if you can tolerate it.

Medications commonly used:

• ACE inhibitors (like lisinopril)
• ARBs (like losartan)

These don’t just lower blood pressure—they also reduce protein leakage in urine, which is a key marker of kidney damage.

Downside? In some people, these meds can temporarily raise creatinine or potassium. I’ve seen patients freak out about this and stop on their own—that’s usually worse. This is where a nephrologist’s judgment is gold: sometimes a mild bump is acceptable because the long‑term kidney protection is worth it.

2. Blood Sugar: If You Have Diabetes

In my experience, people underestimate just how much tight, consistent blood sugar control matters.

Newer diabetes meds called SGLT2 inhibitors (like empagliflozin, dapagliflozin) have been game‑changers. Large trials such as DAPA-CKD (2020) showed these drugs can slow kidney decline and reduce progression to kidney failure, even in some people without diabetes.

Caveat: At Stage 4, not everyone is eligible (eGFR threshold matters), and there can be side effects like genital yeast infections or dehydration. But for many, they’re absolutely worth asking your nephrologist or endocrinologist about.

The “Renal Diet” (Without Losing Your Mind)

Food becomes a daily negotiation when kidneys are struggling. I once sat with a patient who sighed and said, “So I can’t eat anything that tastes good?” That’s not quite true, but the guardrails do get tighter at Stage 4.

Protein: Not Too Much, Not Too Little

Your kidneys have to clear the waste from protein metabolism. Too much protein = more work.

Many nephrologists aim for around:

• 0.6–0.8 g of protein per kg of body weight per day in Stage 4, depending on your situation.

For a 70 kg (154 lb) person, that’s roughly 42–56 g protein/day. When I tracked this for a relative, we realized they were eating almost double that—no wonder their BUN (blood urea nitrogen) was climbing.

But swinging too low is a problem too: muscle loss, weakness, poor wound healing. This is why a renal dietitian is crucial. I’ve seen them rescue people from both over-restriction and silent overload.

Sodium: The Water Magnet

Too much salt pulls in fluid, raises blood pressure, and can leave you swollen and breathless.

Most Stage 4 patients are told to aim for:

• <2,000 mg sodium/day

What surprised me when I actually started reading labels: a single restaurant meal can blow that number out of the water.

Pro tip from experience:

• Anything canned, boxed, or frozen? Flip it over and check sodium. “Healthy‑looking” soups and veggie burgers are often salt bombs.

Potassium and Phosphorus: The Sneaky Two

As kidney function declines, these minerals can build up.

• Potassium: Too high can trigger dangerous heart rhythms.
• Phosphorus: Too high can damage bones, blood vessels, and heart.

Some people in Stage 4 still handle potassium fine; others don’t. I’ve seen two patients with the same eGFR but very different potassium levels. That’s why lab trends > generic lists.

You might be told to:

• Limit high‑potassium foods (bananas, oranges, potatoes, tomatoes, some beans)
• Watch high‑phosphorus foods (cola, processed meats, cheese, nuts, many packaged foods with “phos-” additives)

And you may be placed on phosphate binders—meds you take with meals that “trap” phosphorus so you don’t absorb as much.

Downside: The diet can feel harsh and confusing. Upside: Once a dietitian helps you build a few go‑to meals, it becomes much more manageable.

Medications You’ll Hear About a Lot

When I reviewed medication lists with patients, we often found a mix of helpful and… let’s just say, outdated choices.

Common meds in Stage 4 CKD include:

• ACE inhibitors / ARBs – Protect kidneys, lower BP
• SGLT2 inhibitors – Slow kidney decline (in eligible patients)
• Diuretics (water pills) – Help with swelling and blood pressure
• Phosphate binders – Control phosphorus
• Erythropoiesis-stimulating agents (ESAs) – Treat anemia when kidneys stop making enough erythropoietin
• Vitamin D analogs / calcimimetics – Help regulate bone and mineral balance

There are trade-offs:

• Diuretics can lead to dizziness or dehydration.
• ESAs can raise blood pressure and, in high doses, increase risk of blood clots.
• Phosphate binders can cause constipation or stomach upset.

I’ve watched people feel overwhelmed by the sheer number of pills. One trick that helped: bringing every bottle to a nephrology appointment once or twice a year and asking, “Is each of these still doing something for me?” You’d be surprised how many non‑essential meds get trimmed.

Dialysis and Transplant: Planning Early Without Panicking

When I first heard the word dialysis, my brain went straight to worst‑case scenarios. But the people I’ve seen do best are the ones who learned about options early instead of waiting until an emergency.

With Stage 4 CKD, you’re in the zone where you should:

• Talk about dialysis options:
• Hemodialysis (HD) – Usually in a center, 3 times a week
• Peritoneal dialysis (PD) – Done at home using the lining of your abdomen as a filter
• Discuss vascular access or PD catheter timing if dialysis looks likely
• Get evaluated for kidney transplant if you’re a candidate

A surprising thing I learned: You can often get on the transplant list before you hit dialysis. That can shave months or years off wait time. The National Kidney Foundation and transplant centers really push this now.

I’ve also met several people who quietly thrived on peritoneal dialysis at home, working jobs and traveling, once they got past the learning curve. It’s not easy, but it’s not the end of your life, either.

The Stuff We Don’t Talk About Enough: Fatigue, Mood, and Daily Life

Stage 4 CKD isn’t just about lab numbers. It’s about:

• Bone‑deep fatigue
• Brain fog on bad days
• Muscle cramps at 2 a.m.
• Constant bathroom calculations when your fluid is restricted

One friend with Stage 4 said, “I look fine on Zoom, but I feel like my battery is stuck at 30%.” That line has stayed with me.

Some things I’ve seen help:

• Treating anemia properly – When hemoglobin comes up, people often feel noticeably more energetic.
• Light activity, not no activity – Short walks, gentle strength work. Deconditioning makes everything worse.
• Mental health support – Anxiety and depression are common and very normal. A therapist who understands chronic illness can be a lifesaver.
• Support groups – Online forums or local kidney groups can give you those “oh, it’s not just me” moments.

And yes, some days will just be rough. Having a “low‑energy day plan” (ready-made meals, looser to‑do list, maybe a show you only watch on those days) can make you feel a bit more in control.

What I’ve Seen Actually Move the Needle

After years of following people with Stage 4 CKD, the patterns are pretty clear to me. The ones who do best usually:

1. Know their numbers – eGFR, creatinine, potassium, phosphorus, hemoglobin, blood pressure. Not obsessively, but enough to notice trends.
2. Show up consistently – To nephrology, cardiology, and diabetes appointments. Missed follow-ups often mean missed chances to adjust treatment.
3. Work with a renal dietitian – Not just one time. At least a couple of times a year as things change.
4. Plan ahead for dialysis and/or transplant – So they’re not hit with it during a crisis.
5. Advocate for themselves – Ask questions, bring a list, bring a friend, say “I don’t understand, can you explain that a different way?”

Is it easy? No. Is every piece of advice realistic for every person? Also no.

But even small moves—cutting back on salt, walking 10 minutes a day, taking meds consistently, asking for a transplant evaluation—can add up to a slower decline and a better quality of life along the way.

You don’t have to become a nephrologist overnight. You just have to become the world’s leading expert on you with Stage 4 CKD—and partner with a medical team you trust.

Sources

• National Kidney Foundation – Stages of Chronic Kidney Disease – Overview of CKD stages, complications, and management
• NIH / NIDDK – Chronic Kidney Disease – Government resource on CKD causes, treatment, and lifestyle
• DAPA-CKD Trial – New England Journal of Medicine – Landmark study on dapagliflozin in chronic kidney disease
• American Heart Association – Blood Pressure and Kidney Disease – How hypertension and CKD interact
• Mayo Clinic – Dialysis Overview – Explanation of hemodialysis and peritoneal dialysis options