The RenalTracker Team
May 5, 2022

I hope you enjoy reading this blog post. It has been written and vetted by RenalTracker's team of kidney experts and researchers. The same team was awarded the KidneyX Prize organized by the American Society of Nephrology and HHS for pre-dialysis solution in Washington DC in 2019.   

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If you have chronic kidney disease (CKD), your diet is an important part of your treatment plan. Your recommended diet may change over time if your kidney disease gets worse.

CKD has five stages where stages 1 and 2 are the mildest. In these early stages, the kidneys aren't functioning at their full capacity. Meanwhile, half of the kidney function has been lost at stage 3, causing other health problems such as high blood pressure and bone problems. CKD reaches stage 4, where  the kidneys can no longer function on their own, and dialysis or a kidney transplant may be needed. 

At stage 4, you may visit your nephrologist every three months for lab tests. Your nephrologist will walk you through your treatment options for kidney failure, including dialysis, transplantation, and palliative care. Stage 5 is the End Stage Renal Disease (ESRD), where the kidney function is below 10-15 percent. The waste and toxins build up becomes life-threatening at stage 5.

A CKD diet is essential in all stages, but it's more crucial for CKD patients at the later stages to slow down the progression of the disease.

What is stage 4 CKD?

When you have stage 4 CKD, your eGFR or the estimated glomerular filtration rate (eGFR, a test that measures your level of kidney function and determines your stage of kidney disease), is between 15 and 29. eGFR is calculated using your serum creatinine, a waste product, in your blood. The formula also considers age, sex, ethnicity, and body size.

This means that your kidneys aren't filtering well the waste out of your blood. This waste can build up in the body, causing other health issues. Even if you get treatment in stage 4, it is still possible for kidneys to fail. Kidney failure happens when GFR is below 15 or kidney function is between 10-15%. Although there is no cure for kidney failure, it is still possible to live a long, fulfilling life. When CKD reaches ESRD, you may need dialysis or a kidney transplant to live.

Stage 4 Chronic Kidney Disease

With proper care, you can prolong your life and live well before kidney failure. To help manage CKD stage 4 and prevent further progression to kidney failure, it is important to follow a specialized diet plan. This includes eating more fruits and vegetables, limiting high sodium foods, avoiding potassium-rich foods like bananas, and monitoring fluid intake.

Stage 4 CKD Symptoms

Stage 4 CKD patients may experience the following:

  • Edema (Swelling of the arms, legs, feet, and hands)

  • Frequent or less urination

  • Lower back pain

  • Muscle cramps

  • Appetite loss

  • Restless legs that result in sleep problems

  • Nausea and/or vomiting

  • Metallic taste in the mouth

  • Difficulty in focusing

  • Numbness or tingling in the toes or fingers

At this stage, you may have protein leaking into your urine. Consult your nephrologist right away if you experience any of these symptoms, especially if you were diagnosed with CKD. In the early stages of CKD, patients may not experience any symptoms. Hence, it's worth checking in with your primary healthcare provider if you experience any of the mentioned symptoms.

Stage 4 CKD complications

Stage 4 CKD complications include hyperkalemia, where your potassium levels get too high, affecting your heart's ability to function. Furthermore, CKD patients may also experience:

  • heart and blood vessel (cardiovascular) problems

  • high cholesterol

  • anemia (low red blood cell count)

  • inflammation of the membrane around your heart (pericardium)

  • weak bones

  • reduced fertility or erectile dysfunction

  • compromised immune system

Treatment options for stage 4 kidney disease

It is always necessary to check in with your nephrologist when you have CKD, so they can recommend a customized treatment for your condition. Usually, stage 4 CKD patients visit their doctor every three months. Your nephrologist may order some tests including checking your blood for other waste products, hemoglobin, calcium, phosphorus, and blood sugar (glucose). Your doctor will also check your blood pressure as well as other conditions including diabetes. Besides helping you protect your kidneys and keep them working as long as possible, your doctor will also help you prepare for a kidney transplant or dialysis. Your nephrologist will walk you through your treatment options, including:


This procedure can be done at home, hospital, or dialysis center where a dialysis machine and a dialyzer are used to filter your blood. The doctor will access your blood vessels via minor surgery in your arm to get your blood into the dialyzer. Based on your medical condition, you and your doctor will decide which place is the best to do hemodialysis.


Peritoneal dialysis (PD) 

In peritoneal dialysis, wastes are filtered through a cleansing fluid that flows through a tube (catheter) into part of your stomach. The lining of your belly serves as a filter and removes waste products from your blood. After the filtering process is done, the fluid gets out of the body through the catheter. There are two kinds of peritoneal dialysis - Continuous Ambulatory Peritoneal Dialysis (CAPD) and Automated Peritoneal Dialysis (APD). Basically, these two treatments are the same, however, the number of treatments and the method differ.

Man having Peritoneal dialysis

Man having Peritoneal dialysis

CAPD is a great way to rid your body of toxins while you go about the day. It's done by placing two quarts (or enough for eight treatments) in an enclosed bag and later draining it through a tube inside yourself. The fluid is drained from the abdomen after the exchange of fluid is done. This process is usually done three, four, or five times in a 24-hour period while you do your usual activities. Every exchange takes an average of 30 minutes. Some CKD patients like to do their exchanges at mealtimes and at bedtime.

Automated Peritoneal Dialysis (APD), also known as Continuous cycling peritoneal dialysis (CCPD), uses a machine that does multiple exchanges at night while you sleep. The machine automatically fills your stomach with dialysate. You must remain attached to the machine for about 10 to 12 hours at night, and then dialysate is drained into a sterile bag that you empty in the morning. With APD, you might have a lower risk of peritonitis (inflammation of the peritoneum) because you connect and disconnect to the dialysis equipment less frequently compared to CAPD.

Kidney Transplant

This surgical procedure is done to replace a damaged or diseased kidney with a healthy kidney from a living or deceased donor. Typically, a kidney transplant is chosen for people with kidney failure than a lifetime on dialysis. It can treat CKD or end-stage renal disease to improve your quality of life and lower the risk of death. While a kidney transplant is a lower treatment cost, it may be riskier for some people. These are people of older age, with severe heart disease, or have other factors that could affect their ability to undergo the procedure safely.

Roasted vegetable; CKDdieting

You can slow down the progression of your CKD by monitoring and managing condition including bone disease, diabetes, edema, hypertension, and high cholesterol. You must take all your medications as advised by your nephrologist to help prevent kidney failure and heart disease.

CKD 4 Diet

If you are living with CKD stage 4 and aren't on dialysis yet, your diet will be focused on limiting or avoiding certain foods that can cause further damage to your kidneys. Stage 4 CKD diet depends on other conditions including hypertension and diabetes. Generally speaking, a diet for CKD should be:


According to Kidney Disease Outcome Quality Initiatives (K/DOQI) Nutrition, a CKD patient may benefit from a protein intake of 0.6 grams per kilogram of body weight when GFR is below 25, or approximately 25% remaining kidney function. Your protein source should be from high protein sources. Consider avoiding processed foods as they are rich in sodium and phosphorus that can be harmful to the kidneys. Including a plant-based diet can be gentle to your kidneys while providing your protein requirements. Following a low-protein diet may protect your kidney, but increase the risk of protein malnutrition. It also decreases the buildup of protein waste in the blood. Always check in with your renal dietitian or nephrologist for your recommended protein intake. Click here to learn more about a plant-based diet.


Limiting phosphorus in your diet can help prevent bone disease, preserve existing kidney function and manage PTH (parathyroid hormone) levels. At Stage 4, the PTH production increase, causing the release of calcium and phosphorus from the bones.

As a result, bones are weakened and the spike of phosphorus and calcium in the body can cause calcification in your heart, blood vessels, and other soft tissues within your body. Your nephrologist will suggest your phosphorus restriction based on your lab results, calcium, and PTH. 


You may need to limit high-potassium foods if your kidneys couldn't remove enough potassium to manage normal blood levels in stage 4 CKD. If your potassium level is too high, consider cutting down on foods such as bananas, oranges, dried fruits, potatoes, avocados, brown and wild rice, dairy foods, beans, peas, nuts, meat, pork, fish, poultry and salt substitute. Your doctor may suggest limiting your potassium intake to 3,000 mg a day. Always check in with your renal dietitian for a custom meal plan and talk to your nephrologist about your potassium restriction.


Other conditions such as fluid balance and blood pressure may affect sodium requirements. Your nephrologist may suggest limiting your intake from 1000 mg to 4,000 mg per day. To lower sodium intake, you must cut out processed and pre-packaged foods.

The Bottomline

Besides following the CKD diet for stage 4, lifestyle changes, such as daily exercise and avoiding smoking and restriction of alcohol can help maintain health. You must discuss with your doctor the treatment plan and with your renal dietitian about your meal plan, so you can optimize managing your condition.