Definition and stages 4-5 of chronic kidney disease
Among individuals with chronic kidney disease, the stages are defined based
on the level of kidney function. Identifying the presence and stage of chronic
kidney disease in an individual is not a substitute for accurate assessment of
the cause of kidney disease, extent of kidney damage, level of kidney function,
comorbid conditions, complications of decreased kidney function, or risks for
loss of kidney function or cardiovascular disease in that patient. Defining
stages of chronic kidney disease requires “categorization” of continuous
measures of kidney function, and the “cut-off levels” between stages are
Stage 4 chronic kidney disease (CKD) is severely reduced kidney function,
15-30% (eGFR 15-29ml/min/1.73m2)
Stage 5 chronic kidney disease (CKD is very severely reduced kidney function
(endstage or ESRF/ESRD), less than 15% (eGFR less than 15 ml/min).
Creatinine and eGFR in an individual are usually quite stable. Deteriorating
renal function needs rapid assessment. Note that chronic kidney disease (CKD)
staging and management outlined below are only applicable to stable renal
function.Treatment Options for Stage 4 Chronic Kidney Disease (CKD)
Assessment and management of stable Stages 4 and 5 chronic kidney disease
Initial assessment is identical to Stage 3 chronic kidney disease (CKD), but
in contrast to Stage 3, referral to or discussion with a specialist service will
be usual. Exceptions to ‘always refer or discuss’ may include patients in
whom:severe renal impairment is part of another terminal illness those in whom
all appropriate investigations have been performed and there is an agreed and
understood care pathway those in whom further investigation and management is
clearly inappropriate.Is Stage 4 CKD (Chronic Kidney Disease) Curable
Initial assessment of stages 4 and 5 chronic kidney disease (CKD)
Is the patient well? Is there a history of significant associated
If assessment is precipitated by a first discovery of elevated creatinine, it
is important to be certain that the value is stable. Maybe there are previously
recorded values? If not, and the patient is well, repeat test within 14 days.
Ideally this sample should be taken after a period of at least 12h without meat
consumption, and the sample must get to the lab or be separated the same day.
Deteriorating renal function needs rapid assessment.
Clinical assessment – especially for sepsis, heart failure, hypovolaemia,
examination for bladder enlargement (imaging indicated if obstruction suspected
from symptoms or examination), cardiovascular syImmunotherapy.
Medication review – any potentially nephrotoxic drugs, or drugs that need
dose alterations when GFR reduced? Is Any Treatment Available for Chronic Kidney Disease Stage 4
Urine tests: dipstick for blood and quantitation of proteinuria by ACR/PCR.
Presence of haematuria or proteinuria may suggest progressive renal disease.
Blood tests: Ca, PO4, Hb.
Imaging – exclusion of obstruction is indicated in patients with singnificant
urinary symptoms or other things to suggest obstruction.Stem Cell Therapy for CKD Stage 5 Patients
As above, referral or discussion is usual. Referral by urgency
Management of stable Stages 4 and 5 chronic kidney disease (CKD)
Typically 3 monthly estimation of
Creatinine and K – hyperkalaemia that is severe or not responsive to changes
in therapy should lead to discussion or referral.
Ca and phosphate – Oral phosphate binders will often be necessary. More on Ca
and phosphate.Stem Cell Therapy Treats Kidney Disease
Urinary protein for ACR or PCR. Note thresholds; ACR 30 or PCR 50 for more
stringent blood pressure targets (and suffix ‘p’ on chronic kidney disease (CKD)
stage), and ACR 70 or PCR 100 for specialist referral/discussion. More on
proteinuria.Shijiazhuang Kidney Disease Hospital
Blood pressure - 140/90 max (130-139/90), or 130/80 max (120-129/80) for
patients with proteinuria: urinary ACR>30 or PCR>50. More on
Cardiovascular risk – advice on smoking, exercise and lifestyle. Consider
cholesterol lowering therapy if already have macrovascular disease, or if
estimated 10 year risk of cardiovascular events =/>20%. More on CV risk in
Immunization – influenza and pneumococcal, plus hepatitis B immunization if
renal replacement therapy contemplated.Shijiazhuang Kidney Disease Hospital
Medication review – regular review of medication to minimise nephrotoxic
drugs (particularly NSAIDs) and ensure doses of others are appropriate to renal
In osteoporosis/ low bone density, do not use bisphosphonates or other agents
that reduce bone turnover without detailed assessment of possibility of renal
osteodystrophy. Specialist discussion required.
I hope you’ll get well soon!