Chronic Kidney Disease - Stages 3b and 4

Reviewed by: HU Medical Review Board | Last reviewed: December 2022

Chronic kidney disease (CKD) is a long-term condition in which the kidneys do not filter waste and extra water properly. CKD tends to get worse over time, especially without treatment and lifestyle changes.1

There are 5 stages of chronic kidney disease. The stages are divided by how well the kidneys' tiny filters are working. Stages 3b and 4 are considered moderate to severe loss of kidney function. These stages are generally when people begin to notice symptoms. These symptoms are signs that the kidneys are not working well.1,2

Stages of moderate to severe CKD

Kidney function is measured using a blood test and a urine test. The blood test is called a GFR (glomerular filtration rate), and it tells the doctor how well your kidneys are working. The urine test checks for protein in your pee.3

People whose kidneys are working normally have a GFR result in the 60 to 100 range and have no protein in their pee. People with moderate to severe kidney disease have a GFR between 15 and 44.1,3

Stage 3b

At stage 3b, there is moderate to severe kidney function loss. The kidneys are not working as well as they should. People in stage 3b have a GFR result of between 30 and 44, which means the kidneys are working only at 30 to 44 percent of normal. There is also protein in the pee.1,4

At this stage, kidney damage cannot be reversed. But many people can prevent more damage with aggressive treatment and lifestyle changes.1,4

While you do not need dialysis at this stage, you do need to begin seeing a nephrologist. A nephrologist is a doctor who specializes in kidney diseases. Your nephrologist may also refer you to a renal dietitian. These healthcare professionals can help you get proper nutrition while changing to a kidney-friendly diet.1,5

You will also need to continue following the lifestyle advice given to people at stages 1 through 3a.

Stage 3b symptoms that you might notice include:4,5

  • Swelling in the face, hands, or feet
  • Feeling weak or tired
  • Dry, itchy skin
  • Pain in the lower back
  • Muscle cramps
  • Trouble sleeping
  • Restless legs syndrome
  • Peeing more or less than your normal
  • Pee that is foamy or darker than your normal

Stage 4

Stage 4 is considered severe kidney damage. At this point, the kidneys are close to not working at all. Your GFR score is between 15 and 29, and there may be protein in your pee.1

At this stage, waste begins building up in your body. This can cause many side effects, including:1,6

  • Rising high blood pressure
  • Anemia (not enough red blood cells in your body)
  • Bone disease
  • Heart disease
  • High phosphorus and potassium levels in the body
  • Acid buildup in the body (metabolic acidosis)

The symptoms of earlier stages become more noticeable in stage 4. You will need to be treated by a nephrologist to help manage worsening symptoms and complications. A nephrologist is a doctor who specializes in kidney conditions. In stage 4, you probably need to be seen by your nephrologist every 3 months to closely monitor your CKD.4,6

Aggressive treatment

People with stage 3b and 4 kidney disease generally need to take more and more medicines to manage their disease and its complications. These medicines include:6

  • High blood pressure drugs, such as ACE inhibitors and ARBs
  • Diabetes drugs
  • Calcium and vitamin D supplements
  • Diuretics
  • Erythropoiesis-stimulating agents (ESAs) or iron supplements

You will also need to stop taking drugs that damage your kidneys, such as certain pain medicines.6

People may tell you to drink more water to slow your kidney damage. But people with CKD need to be careful about how much water they drink. Studies show that drinking too little or too much water can make GFR test results worse. Talk to your doctor about how much water you should drink.7

Preparing for kidney failure

At stage 4, your doctor will begin talking to you about your treatment options for when you enter kidney failure. Your options include dialysis, kidney transplant, or neither.5

If you do not pursue dialysis or a transplant, you can continue to treat your symptoms, but you will not survive. You may wish to attend a class to learn more about which option may be the best choice for you.5

Learn more about the other stages of chronic kidney disease:

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