What is the treatment for Chronic Kidney Disease (CKD) stage 4?

Treatment for CKD Stage 4

For patients with CKD stage 4 (GFR 15-29 mL/min/1.73 m²), the primary focus is evaluating and treating complications of advanced kidney disease, preparing for renal replacement therapy, and aggressively managing cardiovascular risk factors to reduce mortality. 1

Blood Pressure Management

• Target systolic blood pressure <130 mmHg if tolerated, though high-quality evidence specifically for stage 4 CKD is limited 1, 2
• Use ACE inhibitors or ARBs as first-line agents in combination with diuretics, particularly if proteinuria is present 1
• For patients without moderate or severe albuminuria, any first-line antihypertensive can be used, though multiple medications are typically required 1
• Loop diuretics are essential for volume management in stage 4 CKD, as thiazides become less effective at this GFR level 1, 2
• Calcium channel blockers (CCBs) can be added as needed for additional blood pressure control 1

Critical caveat: Most major trials, including SPRINT, excluded patients with advanced CKD, so blood pressure targets for stage 4 are largely extrapolated from earlier stages 1

Diabetes Management (if applicable)

• Target HbA1c <7% for most patients with diabetes and CKD stages 1-4 1
• SGLT2 inhibitors should be used in patients with type 2 diabetes and CKD for cardiovascular and kidney protection 1
• GLP-1 receptor agonists are recommended for patients not achieving glycemic targets despite metformin and SGLT2 inhibitors, prioritizing agents with documented cardiovascular benefits 1
• Nonsteroidal mineralocorticoid receptor antagonists (MRAs) like finerenone may be added to RASi and SGLT2i therapy, with careful potassium monitoring 1
• Monitor HbA1c every 3 months if therapy has changed or goals are not met 1

Evaluation and Treatment of Complications

Stage 4 CKD requires systematic evaluation for multiple complications 1:

• Anemia: Monitor hemoglobin levels; initiate erythropoiesis-stimulating agents (ESAs) when hemoglobin <10 g/dL, targeting levels sufficient to reduce transfusion needs without exceeding 11 g/dL 3
• Mineral bone disease: Monitor calcium, phosphorus, PTH, and vitamin D levels; treat hyperphosphatemia with dietary restriction and phosphate binders 1, 4
• Metabolic acidosis: Consider treatment when serum bicarbonate <18 mmol/L to prevent clinical complications 1
• Hyperkalemia: Monitor potassium regularly, especially when using RASi or MRAs; implement dietary potassium restriction and consider potassium binders if needed 1
• Volume overload: Assess for signs of fluid retention; adjust loop diuretic dosing accordingly 2
• Cardiovascular disease: Screen for and aggressively treat cardiovascular risk factors, as CVD is the leading cause of death in CKD 4

Nephrology Referral and Preparation for Renal Replacement Therapy

• Immediate nephrology referral is mandatory for all patients with stage 4 CKD 2, 5
• Begin education about kidney failure treatment options including hemodialysis, peritoneal dialysis, kidney transplantation, and conservative management 2
• Establish vascular access planning for hemodialysis or peritoneal dialysis catheter placement well before anticipated need 1
• Evaluate transplant candidacy early, as preemptive transplantation offers the best outcomes 4

Medication Management

• Review and adjust all medications for reduced GFR, including antibiotics, oral hypoglycemics, and other renally cleared drugs 4
• Avoid nephrotoxins, particularly NSAIDs, which can precipitate acute kidney injury 4
• Discontinue metformin if GFR falls below 30 mL/min/1.73 m² due to lactic acidosis risk 1

Cardiovascular Risk Reduction

• Initiate statin therapy for lipid management, as CKD stage 4 represents very high cardiovascular risk 6, 4
• Target LDL-C ≤55 mg/dL (1.4 mmol/L) with at least 50% reduction from baseline 6
• Consider combination therapy with ezetimibe if statin monotherapy is insufficient 6

Monitoring Frequency

• Monitor renal function, electrolytes, and volume status every 1-2 weeks initially, then monthly once stable 2
• Track rate of GFR decline to estimate timing of renal replacement therapy 1
• Serial monitoring of complications (anemia, bone disease, acidosis) at regular intervals 1, 4

Lifestyle Modifications

• Dietary sodium restriction to <2 g/day to aid blood pressure control 1
• Protein restriction to 0.6-0.8 g/kg/day may slow progression, though must balance against malnutrition risk 4
• Potassium restriction for patients with hyperkalemia or at high risk 1
• Smoking cessation, weight management, and regular physical activity are essential 6