# Treatment options for chronic kidney disease stage 4-5
In chronic kidney disease stage 4-5, kidney function is severely reduced. Treatment focuses on slowing further decline, preventing and managing complications, and preparing for kidney function replacement (dialysis or transplantation). The approach is multidisciplinary and individually tailored.
Blood pressure reduction
High blood pressure is both a cause and a consequence of kidney disease and accelerates further kidney damage. Blood pressure reduction is a central pillar of treatment.
**ACE inhibitors and angiotensin II receptor blockers (ARBs)**
ProveniIncluded in official guidelines, or approved by EMA or FDA
These medications dilate blood vessels around the kidneys and reduce pressure on kidney tissue. They are first-line agents in chronic kidney disease and provide a protective effect on the kidneys. They are often used in combination with other blood pressure-lowering agents. Known side effects include cough (particularly with ACE inhibitors), elevated potassium levels, and mild dizziness upon standing.
**Calcium channel blockers and diuretics**
ProveniIncluded in official guidelines, or approved by EMA or FDA
Calcium channel blockers relax blood vessel walls. Diuretics (water pills) reduce fluid retention, which is particularly important in advanced kidney disease with fluid accumulation. The choice and dosage depend on the individual situation and how well the kidneys are still functioning.
Reduction of proteinuria (protein excretion)
A higher protein level in the urine indicates kidney damage and accelerates further decline. Medications that reduce protein excretion help the kidneys function longer.
**SGLT2 inhibitors (gliflozines)**
ProveniIncluded in official guidelines, or approved by EMA or FDA
These medications reduce the reabsorption of glucose in the kidneys, causing more glucose to be lost through the urine. This unexpectedly also has a protective effect on kidney tissue, independent of blood sugar. They slow the decline in kidney function and also reduce the risk of heart disease. Possible side effects include genital infections, dry mouth, and sometimes dehydration.
**Selective aldosterone antagonists**
ResearchediPositive results in clinical studies, not yet standard treatment
Aldosterone is a hormone that promotes fluid and sodium retention and can damage kidney tissue. Medications that block aldosterone can provide additional protection alongside ACE inhibitors or ARBs. Physicians monitor this carefully because potassium levels can rise.
Treatment of complications
In stages 4-5, complications often develop that require separate attention.
**Treatment of anemia**
ProveniIncluded in official guidelines, or approved by EMA or FDA
When the kidneys cause anemia through insufficient production of erythropoietin (the hormone that stimulates red blood cell production), medications can help the body produce more red blood cells. This improves fatigue and exercise capacity. Side effects can include thrombosis (clots) and elevated blood pressure, especially with rapid correction.
**Treatment of bone disease**
ProveniIncluded in official guidelines, or approved by EMA or FDA
When the kidneys cannot properly convert vitamin D, calcium levels can drop and phosphate levels can rise. This leads to weak bones (kidney bone disease). Calcium supplements, vitamin D-like medications, and phosphate binders (substances that bind phosphate in the stomach) are used. Blood pressure-lowering medications can sometimes also be combined with potassium reduction.
**Treatment of hyperkalemia (too much potassium)**
ProveniIncluded in official guidelines, or approved by EMA or FDA
In severe kidney failure, potassium can accumulate and cause heart rhythm disturbances. Medications can direct potassium to the intestines or remove it from the body. In urgent cases, glucose with insulin is sometimes given to push potassium into cells.
Nutrition and lifestyle
Although not always considered a 'medication', dietary adaptation forms a fundamental treatment pillar.
**Restriction of salt, phosphate, and potassium**
ProveniIncluded in official guidelines, or approved by EMA or FDA
Patients with stage 4-5 typically receive nutritional counseling. Salt restriction helps control blood pressure and fluid retention. Limiting phosphate (less meat, dairy, nuts, grains in certain amounts) helps maintain phosphate balance and prevent bone disease. Potassium restriction (less banana, dried fruit, certain vegetables) prevents accumulation. This requires careful guidance from nutritionists.
**Protein intake**
Studies suggest that targeted protein restriction may help slow kidney decline, particularly in combination with ACE inhibitors or ARBs. This is more complex than it appears and requires individual assessment. Nutritionists help find the right balance between adequate protein intake and kidney protection.
Preparation for kidney function replacement
At stage 4-5, preparation for dialysis or transplantation is essential.
**Creating access routes for dialysis**
ProveniIncluded in official guidelines, or approved by EMA or FDA
A fistula (artificial connection between artery and vein in arm or leg) or dialysis catheter is carefully created so dialysis can start when needed. This is done much earlier than dialysis actually begins, to prevent complications.
**Evaluation for transplantation**
ProveniIncluded in official guidelines, or approved by EMA or FDA
Candidates for kidney transplantation undergo extensive screening (heart, lung, infection, cancer tests). Immunosuppressants (medicines that suppress the immune system so the transplanted kidney is not rejected) are prepared. Patients receive counseling about lifelong immunosuppression and regular check-ups.
Tests and monitoring
Regular blood tests (creatinine, urea, potassium, phosphate, calcium) and urine tests monitor kidney function and complications. These determine whether treatment needs to be adjusted.
Experimental and investigated approaches
**Non-steroidal mineralocorticoid receptor antagonists (NMRA)**
ResearchediPositive results in clinical studies, not yet standard treatment
Substances such as finerenone suppress inflammatory processes in kidney tissue and slow kidney disease. This is new territory with positive study findings.
**Atrasentan**
ResearchediPositive results in clinical studies, not yet standard treatment
This medication inhibits endothelin receptors, which counteracts vasoconstriction and reduces fluid retention. Studies show beneficial effects on protein excretion.
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_This information never replaces a doctor's judgment. Always discuss your situation with your own healthcare provider._