Hey everyone, welcome back to the Chronic Kidney Disease podcast. I'm Jack Smith, your host, and today we're taking a closer look at Stage 4 CKD through a real-life case. So—let's meet Maria L. She's 62, she's got a long history of type 2 diabetes, hypertension, and hyperlipidemia. She comes into the clinic saying, “I feel tired all the time and my legs are swelling.” And honestly, if you’ve worked the floor, you've probably heard these words on repeat from folks grappling with advanced kidney issues.Now, a lot of the symptoms Maria’s showing are textbook for worsening CKD—fatigue, some generalized weakness, and peripheral edema that hits the legs first. She’s also got decreased urine output, which is always a red flag, and then there’s pruritus—that’s just a fancy way of saying her skin’s itching, a lot—even with lotion, it just doesn’t stop. Other things she mentions? Metallic taste in her mouth, nausea on and off, and a hard time focusing. You know, that “brain fog” that drives people nuts—she described it like she’s in a daze half the time.Now, here’s why all these details matter. Fatigue and edema signal volume overload, and with CKD, toxins build up in the blood, so pruritus and that gross metal taste, those are classic “uremic” symptoms. But, the confusion sometimes worries people the most—families call me panicked that mom or dad is acting “off.” I actually had a patient last year, not Maria but similar, who came in for “a little confusion.” Labs showed her creatinine shot up in just a few days. We caught it before it got worse, but it started so subtle—like a, “Where did I set my phone?” turning into “What day is it?” If you catch those changes early, you can keep things from spiraling. It’s one thing to read about these symptoms, but seeing them in a real patient, it just sticks with you.So with Maria, it’s not just about her feeling tired. Each symptom tells us her kidneys are struggling and those toxins are backing up. And if we don’t get ahead of it, the whole body pays—skin, brain, you name it.Alright, so let's dive into the labs, which is where the picture really sharpens up. Maria’s got a serum creatinine of 4.8. Her BUN is way up at 58. GFR’s at 18—that clearly lands her in Stage 4 territory. She’s got some other big hitters, too: her potassium is 5.9, calcium’s 7.8, phosphorus is 6.2, hemoglobin 9.2. And her urinalysis? Proteinuria and microalbuminuria all the way.Now, what do these numbers actually mean? Well, as the GFR drops—less than 30 is entering real danger territory—your kidneys can’t filter out waste, so wastes like creatinine and BUN go up. That also means trouble with keeping electrolytes in balance. Hyperkalemia—that’s the high potassium—is a big deal, 'cause the heart doesn’t like potassium extremes. Hers is just shy of 6, and her ECG even shows those peaked T waves, which is pretty classic for elevated potassium. Definitely not the time to ignore an abnormal rhythm strip.The anemia? That’s because the kidneys aren’t making enough erythropoietin, so the bone marrow slacks off. Maria’s hemoglobin at 9.2 is pretty low, and that partly explains why she feels so wiped out—she’s not getting enough oxygen around her body.Then we’ve got calcium and phosphorus being off—the kidneys, when they’re healthy, help keep those in check. When function tanks, you get hypocalcemia and hyperphosphatemia, which can end up causing bone disease down the line and also keep adding to fatigue and skin problems. And if you see protein in the urine like Maria has, that’s actually a direct marker of glomerular damage. We touched on that in our last episode—a little protein slip early on is sometimes your only clue that something’s wrong.Putting it all together, all these lab changes reflect just how much strain her body’s under. It’s not just a kidney problem; every organ system starts to feel the effects. That’s why tracking labs over time—not just a one-off—tells you if your interventions are working, or if things are heading south.So, let’s talk about what we can actually do for Maria, and the real nuts and bolts of nursing care right at the bedside. First up: medication management. She’ll need things like phosphate binders to keep those phosphorus levels from climbing, antihypertensives to get her blood pressure under better control, and ESAs—erythropoiesis-stimulating agents—to help that anemia. Sometimes diuretics come into play if she’s got fluid overload, but you gotta watch those labs on the daily.Nutrition-wise, it gets tricky. We’re looking at low-protein, low-potassium, low-phosphorus diets—which is, well, easier said than done. I once spent twenty minutes trying to explain to someone why bananas are out and why they can’t just pile on the cheese. Where was I going with this? Oh right—dietary restrictions are tough! And it gets more complicated if you’re also watching fluid, especially if they’re heading towards dialysis.Education is huge here. Maria and her family need to understand why these meds matter, why every pill counts, and what warning signs to look for—like chest pain, more confusion, or if the swelling suddenly gets worse. One thing I like to do is get the family involved in blood pressure checks at home. I remember coaching a patient and her daughter through taking her BP at the kitchen table, and, honestly, it was a learning curve for both of us. People get overwhelmed switching to low-protein diets, so you’ll be troubleshooting almost every follow-up call, trust me.For discharge, it’s all about making sure Maria has her follow-up set with nephrology, a list of her new meds, and simple written diet guidelines—nothing fancy, just practical. We’ll usually pull in social work to help with things like transportation or figuring out how to get started with dialysis, if it comes to that. Reminding folks when to go to the ER—like, if there’s sudden confusion or chest pain—is another big teaching point. The more we involve the family, the more successful the transition home will be.Alright, that wraps up our deep dive into Stage 4 CKD, Maria's journey, and the hands-on care behind the numbers. As always, thanks for listening—hope this gives you a clearer picture of what it takes to manage these complex cases. Next time, we’ll look at dialysis prep and what patients really want to know before starting treatment. See you then!

Episodes

Understanding Stage 4 CKD: A Closer Look