From the Guidelines
For Regina in CKD 4, the primary goal is to minimize the risk of progression to kidney failure and manage complications, with a focus on cardiovascular diseases, hospitalization, and other related risks, as outlined in the KDIGO 2024 clinical practice guideline 1.
Key Considerations
- The management of CKD stage 4 involves a comprehensive approach to slow disease progression and reduce the risk of complications.
- According to the KDIGO 2024 guideline, minimizing the risk of progression to kidney failure is a key outcome, along with managing the risk and appropriate treatment of complications 1.
- The guideline emphasizes the importance of evaluating and managing CKD outcomes, including cardiovascular diseases, hospitalization, and other related risks.
Management Strategies
- Referral to a specialist for consultation and comanagement is recommended if the patient's personal physician cannot adequately evaluate and treat the patient, particularly for patients with a GFR less than 30 mL/min per 1.73 m^2 1.
- Preparation for kidney replacement therapy should begin during stage 4, well before the stage of kidney failure, with initiation of dialysis and transplantation triggered by the onset of uremic symptoms 1.
- Evaluation and treatment of other complications of decreased GFR, such as anemia, malnutrition, bone disease, neuropathy, and decreased quality of life, should be undertaken during stage 3 and continued in stage 4 1.
Monitoring and Treatment
- Hemoglobin levels should be monitored regularly, with a target of 10-11.5 g/dL, avoiding levels above 13 g/dL due to increased cardiovascular risks.
- Iron supplementation is essential before and during ESA therapy, with a target ferritin >100 ng/mL and transferrin saturation >20% 1.
- Blood pressure should be well-controlled before starting ESAs, as these medications can worsen hypertension.
From the Research
Chronic Kidney Disease (CKD) Stage 4
- CKD stage 4 is characterized by a significant decline in kidney function, with an estimated glomerular filtration rate (eGFR) of 15-29 mL/min/1.73m² 2.
- Patients with CKD stage 4 are at increased risk of progressing to end-stage renal disease (ESRD) and require close monitoring and management to slow disease progression.
Management of CKD Stage 4
- Angiotensin-converting enzyme inhibitors (ACEis) and angiotensin II receptor blockers (ARBs) are recommended for patients with CKD stage 4 to reduce proteinuria and slow disease progression 3, 4.
- The optimal dose of ACEi or ARB for renoprotection is not well established, but higher doses may be associated with greater anti-proteinuric effects 4.
- A study found that only 29.8% of patients with proteinuria were taking maximal ACEi/ARB doses, suggesting that greater attention toward optimizing the dose of ACEi/ARB therapy may be needed to improve CKD care 5.
Outcomes in CKD Stage 4
- A study found that dipstick-positive proteinuria was independently associated with mortality and first morbid event in patients with heart failure, including those with CKD 2.
- Another study found that ACEi or ARB may prevent kidney failure and reduce the risk of doubling of serum creatinine in patients with diabetes and kidney disease, but the evidence is of low certainty 6.
- The effects of ACEi or ARB on cardiovascular outcomes in patients with CKD stage 4 are not well established, and further studies are needed to determine the optimal treatment strategy 6.