Stage four represents the beginning of advanced kidney disease. Kidney function is 15 to 29 percent of normal, and the GFR is 15 to 29 ml/min. When you reach this stage, your kidney doctor will look for ways to maximize your remaining kidney function, as well as introduce a treatment plan that includes going for a transplant evaluation and preparing for dialysis.
|Stage 4 Kidney Disease Prognosis|
In the best case scenario, you will already have a kidney doctor following you prior to this stage. Referral to a kidney specialist at this point is too late, because the kidney disease is so advanced that there is often little chance of improving kidney function. Unfortunately, time and again nephrologists are first consulted at this irreversible stage, but the window of opportunity to improve kidney function has already been lost.
When your kidney function is less than or equal to 20 percent (GFR < 20 ml/min), your kidney specialist will discuss referral to a dedicated transplant center for an evaluation. There is evidence that people do better when they are transplanted earlier, before dialysis is even started. Therefore, early intervention is encouraged because the transplant evaluation is a long process.
Transplant evaluation is important for determining eligibility for a kidney transplant. Factors such as age and the cause of your kidney disease are important considerations. Other medical conditions such as diabetes, heart and lung problems, and vascular disease are also important factors in determining if you are a suitable candidate.
As a potential transplant candidate, you will undergo thorough, lengthy evaluations by a transplant surgeon, a transplant nephrologist, or another member of the transplant team. Additional physicians, including heart doctors (cardiologists) and other medical sub-specialists are also involved in the evaluation process as needed. Sometimes, if there has been a change in one of your other medical conditions or if you are ill, the evaluation process is temporarily put on hold.
When the testing is complete, you will be placed on a transplant waiting list if you are approved. Family members or close friends can then be tested to determine if they are able to donate a kidney to you. This is strongly encouraged, as, given the shortage of available kidneys, a person could be on the list for a long time.
At this advanced stage, you will most likely be informed about dialysis, including the various options and types, of which there are several. Dialysis is not actually needed at this stage, but there is so much that goes into its preparation that beginning to talk about it is recommended.
Dialysis is an "artificial filtering process" that does the job the kidneys are no longer able to do. Hemodialysis (HD) is the most common type. With it, you are connected to an HD machine that filters, cleanses, and returns your blood through an access. There are several types of accesses, including a catheter and a graft, but the best type of access is called a fistula (fis-chu-la).
A fistula is created by a vascular surgeon, usually in the non-dominant arm - the one you don't write with or use often. A well-functioning fistula allows you to get an excellent dialysis treatment. After surgery, it can take two to four months before a fistula can be used.
Because of the amount of time it takes - including the evaluation by the vascular surgeon, the surgery itself, as well as the time it takes for the fistula to mature - the kidney specialist will begin discussing this very important preparatory step at stage four.
An HD treatment is usually three to four hours long, and occurs three times a week. You can decide on a schedule to accommodate your lifestyle. There are even a couple of newer options from which to choose. One includes nocturnal dialysis, which involves doing dialysis overnight three times a week at dedicated "nocturnal units." And more recently, home hemodialysis is becoming an increasingly popular alternative.
Here, after a few weeks of training, you are doing a similar type of dialysis at home using a small, portable HD unit. You and a partner of your choice - it is recommended to train someone else, as well, but not necessary - are essentially doing what the nurse or technician does at the dialysis unit. There is great flexibility with home HD; on average, a person will do four to five treatments a week for two to three hours at a time.
Another type of dialysis is called peritoneal (perry-toe-neil) dialysis (PD). This involves a special kind of catheter that is placed in your belly by a surgeon. A series of exchanges is then performed throughout the day. With each exchange, the belly is filled with about two liters (two quarts) of a glucose-based fluid. There is then a "dwell period" where the fluid remains in the belly and the dialysis "is being done." Each dwell period can last anywhere from two to four hours. The fluid is then drained from the catheter. An advantage of this type of dialysis is that it can be done at home. However, many people find it hard to get used to the idea of carrying fluid around in the belly.
Alternatively, PD exchanges can be done by an automated system where the exchanges are done at night via a machine called a cycler. If a person has had multiple surgeries in his belly, he may not be a candidate for PD. Like home HD, PD requires several weeks of training, usually done by a dedicated dialysis nurse along with your doctor.
All of this information can be overwhelming for patients to digest. For that reason, I prefer to discuss this life-altering process over two or three visits with family members present whenever possible. Dialysis is a bridge to transplantation for many patients. It is important to get evaluated as soon as you are able, while considering all of your options. To find out more, you can check out Stage 4 Kidney Disease Prognosis.