Chronic Kidney Disease: The 5 Stages

Chronic kidney disease is a condition defined by the damage to the kidneys that is often gradual and long lasting. A person with chronic kidney disease must first understand that he is a constituent of one of the five stages that determine this disease. With every stage the problems and symptoms are likely to intensify and become more brutal. The bad news is that CKD is most likely irreversible but the good news is that it takes its own sweet time to progress and advance. With this good news comes even greater news for CKD patients: they have the remote control of their lives in their own two hands and therefore a chance to feel wholesome and healthy with medicines and lifestyle changes. For this great news to knock on your doors, you first need to tutor yourself about the five stages of CKD, their symptoms and the importance of early diagnosis since the earlier you are diagnosed, the more chances you have to turn the situation around in your favour.

Glomerular Filtration Rate

A healthy kidney is capable of ridding the body off of toxic substances and other waste materials. It is also responsible for boosting the bloodstream with vitamins, amino acids, glucose, hormones and other vital substances. As per KDOQI (Kidney Disease Outcomes Quality Initiative) and KDIGO (Kidney Disease: Improving Global Outcomes) guidelines, decrease in kidney function or damage to the kidneys persistently for a period of three or more months irrespective of the reason behind the issue differentiates CKD from Acute Kidney Disease.

To determine the kidney’s health and if it is functioning properly, the best measure is through the estimated Glomerular Filtration Rate (eGFR). This filtration rate is estimated by the amount of creatinine in the blood. The higher the amount of creatinine (waste product) in the body, the less it is being filtered by the kidney. Therefore, the higher the filtration rate, the better the kidney is functioning and the lower the rate goes, the less the kidney is able to perform its functions properly.

Kidney damage is indicated by pathologic abnormalities that may be identified by imaging studies or biopsy or may be established from different markers such as increased rates of excretion of urinary albumin or urinary sediment abnormalities.

Five Stages of CKD

Each stage of CKD is unique in its own right, with its specific set of symptoms, complications, medications and treatment options. Stage 1 means that the patient has the least damaged kidney while stage 5 means that the patient’s kidney damage has reached at the stage where he/she requires a transplant or dialysis to live.

Identifying the stage of CKD, helps to guide disease management, understand the risk factors for progression and any possible complications that may arise. This can further facilitate taking informed decisions regarding appropriate treatment, patient monitoring and education. 

Staging of CKD can be done in accordance to the cause of disease, according to the GFR and as per albuminuria. Identifying patients according to these stages helps in risk stratification for predicting the complications of CKD. Low GFR indicates more chances of complications than in case of high albuminuria.

Staging according to Cause

Kidney disease may be caused by urinary tract obstruction, diabetes, auto-immune disease, drug toxicity, kidney transplantation etc. Identifying the underlying cause behind the disease enables appropriate therapy specifically directed towards further damage. Additionally, the cause behind CKD has further implications on the rate at which disease progresses and the risk of complications. However, generally ascertaining the cause of CKD proves difficult and mostly it is discovered during the evaluation and treatment of other medical issue as decrease in eGFR.

Staging as per Albuminuria

The three categories of CKD stages as per Albuminuria (A stages) include Normal albuminuria, increased moderately (earlier referred as microalbuminuria) and increased severely (earlier referred as macroalbuminuria). The severely increased albuminuria falls in the nephritic range.

  • A1 Stage – ACR < 30mg/g (<3.4 mg/mmol)
  • A2 Stage – ACR 30 to 299 mg/g (3.4 to 34.0 mg/mmol)
  • A3 Stage – ACR >= 300 mg/g (>34.0 mg/mmol) 

(Definition and staging of Chronic Kidney Disease in Adults, Andrew S Levey, Lesley A Inker, YEAR)

The staging of CKD as per Albuminuria has been added in addition to GFR staging due to the added risk in mortality, CKD progression and occurrence of ESKD when levels of albuminuria become higher, independent of eGFR, in the absence of an apparent threshold value. It has been observed that even when GFR value is >60 mL/min per 1.73m2, urine ACR values > = 30 mg/g significantly increase the risk of CKD, that is consistent with the current marker threshold value of kidney damage for albuminuria (>= 30 mg/g). Even with urine ACR values between 10-29 mg/g which is considered “high normal” albuminuria level, there is an apparent increase in risk of CKD calling for higher attention when albuminuria levels drop below 30 mg/g. *This paper confirms, can be used as citation/reference(Definition and staging of Chronic Kidney Disease in Adults, Andrew S Levey, Lesley A Inker, YEAR)

Staging as per GFR

According to GFR, CKD is classified into 5 stages (G stages) among which CKD 3 is divided into 3a and 3b to reflect more accurately, the consistent association between adverse results of kidney disease and risk of mortality with low GFR. Stage 5 includes patients who are on dialysis treatment to highlight the need for specialized attention and care for them.

  • G1 Stage – GFR >90 mL/min per 1.73 m2
  • G2 Stage – GFR 60-89 mL/min per 1.73 m2
  • G3a Stage – GFR 45-59 mL/min per 1.73 m2
  • G3b Stage – GFR 30-44 mL/min per 1.73 m2
  • G4 Stage – GFR 15-29 mL/min per 1.73 m2
  • G5 Stage – GFR <15 mL/min per 1.73 m2

STAGE 1:

In this first stage, the individual’s GFR is 90 or above, indicating that the kidneys are functioning at 90% or better. The kidneys function efficiently even when they are not functioning at 100 percent and because of this very reason, many people who enter stage 1 of CKD are asymptomatic. Although the filtration rate seems to be normal but there might be other complications such as presence of proteins in the urine.

What gives away the fact that you have entered stage 1 of kidney disease?

Since symptoms do not show as much in this stage, many get to know that they have kidney disease accidentally, such as when they are getting tested for diabetes or high blood pressure. A few telltale signs are swelling in legs or high blood pressure. One can also discover about this condition via blood (serum) test, urinalysis (urine test) and imaging test such as MRI or CT scan. Some signs of Stage 1 of CKD that can be uncovered via these tests are:

If you are fortunate enough to get diagnosed early, you must start making certain changes in your lifestyle such as:

  • Eat a healthy diet that incorporates variety of whole grains, fruits, vegetables.
  • Include physical activity such as jogging or walking in your daily routine
  • Follow a diet that is low in saturated fats ad moderate in total fats
  • Limit the use of high sodium ingredients
  • Keep a check of your blood pressure
  • Keep a check of blood sugar or diabetes
  • Go for regular check-ups and tests to see if the disease has progressed
  • Quit smoking and the use of tobacco products
  • Take your medications (doctor recommended)
  • Maintain a healthy body weight

Early diagnosis and intervention might give you the chance to control your disease and prevent it from escalating rapidly, so don’t get worked up if you find yourself in this stage. Start making these lifestyle changes and manage the various risk factors. This may give a shot of health to your kidneys and an opportunity to lead a long and wholesome life.

STAGE 2:

Characterised by a decrease in the GFR, which ranges between 60-89 ml/min., Stage 2 is the next stage of CKD. Patients in this stage still largely remain asymptomatic, however certain symptoms to be vary of, include:

  • Darker urine ranging between the shades of yellow, red and orange
  • Muscle cramps at night
  • Lower back pain
  • Insomnia
  • Fatigue and weakness
  • Change in the pattern of urination (increased or decreased)
  • Fluid retention
  • Dry skin or itchy skin

Transition from stage 1 to stage 2 is characterised by a slight decrease in kidney function. Certain indicators of this damage are:

  • High level of urea or creatinine in the blood
  • High amount of blood or protein in the urine
  • Kidney damage seen in MRI, CT scan etc
  • Family history of polycystic kidney disease (PKD)

How to cope with the stage 2 of CKD?

If you have been diagnosed with CKD and find yourself in stage 2, all hope is not lost. You can still slow down the progress of CKD with the right medications and lifestyle changes. Some integral changes that you must incorporate in your life are:

  • Quit smoking or consuming tobacco products
  • Dietary changes by avoiding high amounts of salt, sugar and processed grains.
  • Incorporate physical activity such as walking, dancing, jogging to stay healthy
  • Control high blood pressure and/or diabetes
  • Get yourself regularly checked to track the kidney damage
  • Visit your doctor regularly and take all his/her recommended medicines and advice seriously
  • Indulge yourself in vegetables, fruits, beans, fish and other whole grains
  • Hydrate yourself by drinking lots of water
  • Take iron supplements to treat anemia and improve fatigue

Since this stage is also asymptomatic, it would be wise to go for regular check-ups to track the advancement of the kidney disease. It is possible to slow down the progression of CKD at this stage provided you make some big and necessary changes in your lifestyle.

STAGE 3:

The GFR in this stage stoops down between 30 and 59. In this stage the kidney disease can only be detected via a blood test. This stage can be broken down into 2: Stage 3a which is an early stage where the eGFR is between 45 and 59 and stage 3b which is a later stage during which the eGFR is between 30 and 44. Stage 3b is worse than stage 3a and symptoms are more likely to show and worsen during stage 3b. These symptoms and other associated conditions include:

  • Back pain
  • Swollen hands or/and feet
  • Unusual pattern of urination in terms of frequency and texture
  • High blood pressure
  • Sleep problems or insomnia
  • Muscle cramps
  • Anemia (shortage of red blood cells)
  • Bone disease
  • Fluid retention
  • fatigue
  • Uremia (when waste products build up in the blood as a result of decreased kidney function, it may cause this condition)

Health care in stage 3 of CKD:

Consulting a nephrologist must be the very first step that a patient who has been diagnosed with stage 3 of CKD should take. A nephrologist is a doctor who specializes in treating kidney disease. They help the patients in keeping their kidneys healthy for as long as possible by devising an action plan and actively working with the patient. They not only help you understand the conditions that worsen the disease but also control them. These conditions are: diabetes, high cholesterol, hypertension, swelling etc. The patient must also consult a certified dietician who will make a meal plan to prevent the disease from spreading further and damaging the overall health even more. Since diet is a huge part of the treatment of CKD, certain points must be kept in mind:

  • Lower calcium consumption
  • Cut back on carbs
  • Decrease saturated fats to keep cholesterol in check
  • Cut out processed and pre-packaged food
  • Consume fruits, vegetables and other grains
  • Eat more whole foods
  • Cut on high potassium foods like bananas, potatoes etc
  • Cut on salty and sugary food
  • Eat more small meals throughout the day

This stage is all about paying visit to your doctor and following their instructions and recommendations, religiously. Your doctors may recommend medicines such as iron supplements, vitamin supplements and other drugs to manage the conditions and symptoms that accompany this stage. He/she may provide ways to manage blood pressure, diabetes and stress via medication or self-care practices such as exercising, meditation etc. There is no cure of CKD but progression might be delayed at this particular stage via some adjustments in one’s lifestyle and following the action plan laid out by the doctor and dietician.

STAGE 4:

A patient diagnosed with stage 4 kidney disease has severely damaged kidneys. The GFR of 15-29 ml/min indicates the amount of blood that is filtered by the kidneys. Owing to this, the patient might suffer from additional conditions such as high blood pressure, erectile dysfunction, reduced fertility, low sex drive, seizures, inflammation of the membrane around your heart, anemia, bone disease, malnutrition, heart disease and other cardiovascular diseases.

Symptoms and signs of stage 4 kidney disease:

  • Fluid retention, swelling of arms/legs (edema)
  • Fatigue, shortness of breath
  • Kidney pain felt in the back
  • Loss of appetite or metallic taste in mouth or bad breath
  • Nausea or vomiting
  • Difficulty in concentrating
  • Numbness in toes or fingers
  • Urination changes in terms of frequency and texture
  • Fluid in the lungs (pulmonary edema)
  • High blood pressure

In stage 4 of CKD, the patient must visit his Nephrologist more often. Regular check-ups would be done to monitor the amount of creatinine, haemoglobin, calcium, phosphorus levels in the body. Underlying conditions such as diabetes, high blood pressure would also be monitored and controlled to slow down the progression of the disease. You must work closely with your doctor who would prepare you for the possibility of you reaching the next stage which is the last stage characterised by kidney failure.

Patients are told that they have the following choices if they reach the fifth stage of CKD:

1) Hemodialysis

2) Peritoneal dialysis

3) Kidney Transplant

Diet in Stage 4 kidney disease:

Visit a dietician, who would review your reports and give you a diet plan that would smoothen out your journey through CKD:

  • Consume fresh foods
  • Avoid processed products
  • Quit smoking and alcohol consumption
  • Avoid salts, sugar, saturated fats
  • If potassium is high, cut the intake of bananas, nuts, pasta, whole wheat bread, oranges etc
  • Lower calcium consumption

Other changes:

  • Exercise at least 30 minutes a day
  • Visit your doctor regularly and follow their medications just as they are recommended
  • Go for routine tests and check-ups
  • Quit smoking and the use of tobacco completely

Careful monitoring and positive intervention may slow down the progression from stage 4 of kidney disease to stage 5.

STAGE 5:

A person with stage 5 kidney disease has end stage renal disease (ESRD). Their GFR is of 15 ml/min or less which indicates that the kidney has failed to perform its functions efficiently and another treatment option is needed.

Symptoms of stage 5 of CKD:

  • Loss of appetite
  • Disturbing sleeping patterns
  • Nausea
  • Vomiting
  • Muscle cramps
  • Back pain or chest pain
  • Being tired or weakness
  • Inability to concentrate
  • Making little or no urine
  • Puffiness around eyes
  • Swelling in the ankles
  • Tingling feeling in hands or feet
  • Change in skin color
  • Increased skin pigmentation

Patients are told that they have the following choices if they reach the fifth stage of CKD:

1) Hemodialysis: this treatment can be done at home or at the health care centre. A small amount of patient’s blood is removed from the body through the dialyzer or artificial kidney. This blood is then filtered which gets rid of the extra waste and toxins. This filtered blood is then returned to the body.

2) Peritoneal dialysis: during this treatment, the catheter carries a cleansing fluid into a part of your abdomen. The lining of the abdomen then acts as a filter and gets rid of all the waste products and toxins from the blood. After a while, this fluid that carries the waste products flows out of the abdomen and is discarded. The preparation of peritoneal dialysis requires minor surgery for the insertion of the catheter.

3) Kidney Transplant: placing a healthy kidney from a donor’s body to the patient’s body via a surgery characterises a kidney transplant. This new kidney filters waste from the blood and helps the body work successfully. However, the patient might have to wait for years before an appropriate donor becomes available and factors such as age and other health conditions are taken into consideration to check and determine if one is even eligible for a kidney transplant.  Until recently matching the blood type of the donor and the recipient was a must for a successful transplant. However, with the advancement in medical techniques, it is now possible to eliminate the reaction of the recipient to blood type incompatibility. As a result, more people can now benefit from kidney transplant from live donors and lead a healthy life. The patient though must also take medications regularly.

Diet in Stage 5 kidney disease:

  • Include fruits and vegetables along with grains but avoid certain grains/fruits/vegetables that are high in phosphorus and potassium
  • Decrease calcium intake
  • Limit fluid intake
  • Limit intake of processed food
  • Limit intake of food that are high in sodium
  • Prepare food with less salt
  • Take vitamins and supplements as suggested by your doctor and incorporate foods that are high in that particular vitamin

Visiting your doctor regularly, following their recommendations and following a diet plan are some key points that are likely to help you beat and bear the atrocities that are a consequence of CKD.

Stay ahead of CKD by gathering efficient knowledge of the same, making lifestyle changes and taking every symptom as seriously as you take your profession and career because there is no greater wealth than having a healthy and functional body.

Breathe health and wellness into your bloodstream. Educate yourself and do not let CKD define you.

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