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Draft: not yet reviewed by a clinician

Use this page to prepare questions for your care team. It does not replace their advice. Your own targets and doses come from your nephrologist, diabetes team and renal dietitian.

Stage G4

In short

G4 means your eGFR has been 15–29 for more than 3 months. It is the planning stage. You may still feel fairly well, but now is the time to learn about every option, from transplant to dialysis to care without dialysis, while you have time to choose (KDIGO 2024, practice point 5.5.1). Ask for a transplant referral now (KDIGO 2020 transplant). Protect the veins in your arms for a future dialysis access (KDOQI vascular access). Your diet tightens a little, and your diabetes care changes: lows become more likely and A1c becomes less reliable (ADA–KDIGO 2022; KDIGO 2022).

Your numbers

Starting points, not your prescription

These numbers are typical starting points from guidelines. Your nephrologist, diabetes team and renal dietitian set your own numbers from your blood tests, urine output and medicines, and change them as your labs change. If your lab report or your team says something different, they win.

Starting numbers at G4 (70 kg adult with type 1 diabetes; the same as the app's "Suggest targets"):

Protein Potassium Phosphorus Sodium Fluid Energy
0.8 g/kg (about 56 g) review ceiling 3,000 mg, only if your blood potassium is high 1,000 mg; cut phosphate additives first under 2,000 mg no set limit unless you have swelling 30 kcal/kg (about 2,100 kcal)

Your planning timeline

When What happens Source
eGFR under 30 You should be told about, and considered for, a kidney transplant KDIGO 2020 transplant, 1.1
At least 6–12 months before dialysis would be needed Referral for transplant evaluation, so a living donor can be found and tested KDIGO 2020 transplant, 1.1.1
eGFR 20 or less, once you are on the US waiting list Your waiting time starts to count OPTN policy 8
2-year kidney failure risk (KFRE) over 10 % Join multidisciplinary kidney care KDIGO 2024, 2.2.2
eGFR 15–20, or 2-year KFRE over 40 % Plan dialysis access and/or a pre-emptive transplant; learn about each treatment KDIGO 2024, 2.2.3 and 5.4.3; KDOQI vascular access, 6.6
Now, if you have Medicare Up to 6 kidney disease education sessions; you pay 20 % after the Part B deductible Medicare

Tests to expect

Test How often
Calcium and phosphate (phosphate typical 2.5–4.5 mg/dL) every 3–6 months
PTH every 6–12 months
Alkaline phosphatase every 12 months, more often if PTH is high
Hemoglobin and iron about twice a year
Check for undernutrition (weight, appetite) twice a year
eGFR, UACR, potassium, bicarbonate 1–4 times a year, as your team decides
Test How often
Calcium and phosphate (phosphate typical 0.81–1.45 mmol/L) every 3–6 months
PTH every 6–12 months
Alkaline phosphatase every 12 months, more often if PTH is high
Hemoglobin and iron about twice a year
Check for undernutrition (weight, appetite) twice a year
eGFR, UACR, potassium, bicarbonate 1–4 times a year, as your team decides

Sources: KDIGO 2017 (recommendation 3.1.2); KDIGO 2026 anemia; KDIGO 2024 (practice point 5.2.3.2).

What changes now

Learn about every option. In-center hemodialysis, home hemodialysis, peritoneal dialysis, a transplant, and comprehensive conservative care (care without dialysis) are all real choices (KDIGO 2024, practice points 5.5.1–5.5.2). The best option for most people who can have one is a transplant from a living donor before dialysis is needed (KDIGO 2020 transplant, 1.4). With type 1 diabetes, ask about a simultaneous pancreas-kidney (SPK) transplant (KDIGO 2020 transplant, 8.1.1). Compare them in Choosing a treatment.

Protect your arm veins. A fistula for hemodialysis needs healthy veins. KDOQI advises avoiding PICC lines and unnecessary needle sticks from stage 3 on, when dialysis may be needed in the future (KDOQI vascular access, statement 6.10). Ask which arm may be used for an access, and ask staff to use the other arm for blood tests and drips. See Dialysis access.

Food. Potassium and phosphorus limits are more often needed now. Cut phosphate additives first: they are almost fully absorbed (KDOQI 2020). Keep sodium under 2,000 mg. Keep protein at about 0.8 g/kg; going lower does not help glucose, the heart or kidney function (ADA 2026 §11, recommendation 11.3).

Diabetes. Insulin needs often fall as eGFR falls, and lows become more likely (JBDS–Renal Association; ADA–KDIGO 2022). Your team, not you, changes the insulin plan. A1c becomes less reliable at G4–G5 (KDIGO 2022, practice point 2.1.2), so your team may lean on CGM time in range instead (practice point 2.2.2). See A1c and CGM metrics.

How people usually feel

Some people at G4 start to feel tired, lose their appetite or feel sick. KDIGO asks kidney teams to ask about these symptoms at every visit (KDIGO 2024, practice point 5.2.2.1). Itch, restless legs and poor sleep are also worth raising (Get help now). Unplanned weight loss is a reason to see a dietitian (practice points 5.2.3.2–5.2.3.3).

What to do

  • Ask for a transplant referral, and ask whether the center does pancreas-kidney transplants.
  • Ask family and friends whether anyone would consider being tested as a living donor.
  • Book Medicare kidney disease education sessions if you have Medicare (ask your doctor for a referral).
  • Ask your team which arm to save for an access. Tell every nurse and lab: "save my veins".
  • Ask about your KFRE and when to plan an access.
  • Ask for a renal dietitian.
  • Ask your diabetes team how they will judge your glucose now: A1c, CGM time in range, or both.
  • Keep glucose tablets and glucagon within reach: lows are more likely now.
  • Set your stage to 4 in the app: the potassium review ceiling becomes 3,000 mg (Targets and warnings).

Examples

A blood test in the "wrong" arm. Your team has said your left arm may be used for a fistula. A nurse at another clinic wants blood from your left elbow. Say: "I have stage 4 kidney disease; please use my right arm to save my veins" (KDOQI vascular access).

Additives first. One ounce of processed American cheese has about 180 mg of phosphorus (USDA), and processed cheese is made with phosphate additives (NKF). A 12 oz cola has about 33 mg by USDA figures, and about 62 mg when measured directly (Di Iorio 2012). Swapping these for unprocessed cheese and a clear soda is an easy first step.

Salt substitutes. A quarter teaspoon of "lite" salt has 350 mg of potassium (Morton). Use herbs, pepper, lemon or garlic instead.

A planning conversation. Your eGFR has gone from 28 to 22 in a year, and your 2-year KFRE is 15 %. That is the point for multidisciplinary care (KDIGO 2024, practice point 2.2.2). Ask about transplant referral now, rather than waiting for eGFR 15.

Ask your care team

  1. What is my KFRE, and when should I plan for an access or a transplant?
  2. Can you refer me for a transplant evaluation now? Does the center do pancreas-kidney transplants?
  3. Which treatment options would suit me? Can I meet people who use them?
  4. Which arm should I protect, and when should I see a surgeon?
  5. Do I need potassium or phosphorus limits, based on my last results?
  6. How will we judge my glucose now that A1c is less reliable?

Get help now if…

Call 911 (or your local emergency number)

Chest pain; severe breathlessness or not being able to lie flat; fainting or a very slow or irregular pulse; new confusion or a seizure; a low the person cannot treat themselves (give glucagon, then call); possible DKA: blood ketones of 3.0 mmol/L or more, or any ketones with vomiting, deep fast breathing or fruity breath (2024 consensus). Full list: Get help now.

Call your care team today

New or worse swelling, much less urine, vomiting or not eating, or lows that keep happening (ADA 2026 §6). A lab potassium of 6.0–6.4 mmol/L: KDIGO advises a repeat test within 24 hours, or checks and treatment in hospital now if you feel unwell (KDIGO 2024, Table 28).

Sources

Not yet reviewed by a clinician. Facts and sources last checked 2026-10-06. Prices and benefit amounts as of 2026-10-06.