You’ve probably seen it on a lab printout: eGFR 24, or 19, or 28, with “stage 4” printed right beside it. And your mind goes straight to dialysis, because that’s what everyone says stage 4 leads to.
It’s a fair worry. But an eGFR between 15 and 29 is a cue to start planning, not a cue to start dialysis. Those are two separate things, and mixing them up causes a lot of sleepless nights, and now and then a rushed decision too.
What a number in the 15 to 29 range actually says
eGFR is an estimate of how much blood your kidneys clean each minute, worked out from your creatinine, age and sex. Healthy kidneys sit somewhere around 90 or above. At 15 to 29, you’re filtering roughly a sixth to a third of that. It’s a serious drop, no point dressing it up.
Still, it’s one reading on one day. A bad week of dehydration, a stomach bug or a new medication can push it down for a while. That’s why nephrologists want a few results over a few months before they treat any number as the real picture. If you haven’t seen the full ladder from stage 1 to 5 yet, the way CKD stages are defined and managed will help you see where 15 to 29 sits.
Why dialysis doesn’t kick in at a set number
This surprises people. The NIDDK, part of the US National Institutes of Health, says that for most people the need for dialysis creeps up slowly. Many start when their kidney function is somewhere between 5 and 10, and what pushes the decision is usually how they feel: appetite fading, muscle loss, that kind of thing. The page was last reviewed in 2018, so your own doctor’s current practice is what counts. Either way, the point stands that a 5 to 10 range sits well below stage 4.
So there’s no line at 15, or 20, or 25 where a switch flips. Some people sit in stage 4 for years and never need dialysis during that time. Others slide faster, or run into trouble with fluid, potassium or acid levels in the blood, and start earlier. Two people with the same eGFR can have completely different timelines. The symptoms and complications that actually tip the decision are covered in more depth in a piece on when dialysis becomes necessary, and it’s worth a read alongside this one.
So what is stage 4 actually for?
Planning. That’s the whole job of this stage.
If you aren’t already seeing a nephrologist, stage 4 is the time to get referred. Not because something dramatic is about to happen, but because the decisions ahead go much better with months of runway instead of days. Roughly, the planning window is for a few things:
- Learning what each treatment involves, before you’re sick enough to be forced into one
- Asking whether you’re a candidate for a transplant (NIDDK notes a transplant centre can list you once your kidney function is 20 or less)
- Getting access sorted out ahead of time, since hemodialysis needs minor surgery to create a vascular access and peritoneal dialysis needs a catheter placed a few weeks before you begin
- Seeing a dietitian, because food and fluid advice changes a lot at this stage
- Talking it through with family, so nobody’s guessing about your wishes later
None of that means you’re starting dialysis. It means you won’t be doing all of it in a hospital corridor.
The options, in plain words
There are four paths, and they’re worth knowing even if you hope never to use any of them.
Hemodialysis runs your blood through a machine outside the body. It’s usually done three times a week for around four hours a session, either at a dialysis centre or, for some people, at home.
Peritoneal dialysis uses the lining of your belly as the filter. You do it at home, either with exchanges through the day or with a machine overnight.
A kidney transplant puts a healthy kidney from a living or deceased donor into your body. It tends to give the best quality of life when it’s possible, but waits for a donor kidney can run to years, and you may need dialysis in the meantime. Some people with a willing living donor skip dialysis entirely.
Conservative management means no dialysis and no transplant. The focus is on symptoms and comfort, and it’s a real, respected choice, especially for people with other serious health conditions. Nobody has to start dialysis, and you can change your mind later in either direction.
One thing none of these do is cure kidney failure. Dialysis replaces part of what the kidneys do, not all of it. If your goal is to keep your own function going as long as you sensibly can, it helps to read how people approach living with kidney disease without dialysis alongside whatever your nephrologist suggests.
Can the number come back up?
Sometimes, a little. If part of the drop came from something temporary, like dehydration, a drug that stresses the kidneys, or an infection, then sorting that out can lift the number. True long-term scarring is a different story, and it rarely reverses. A good explanation of what is and isn’t realistic sits in whether kidney function can improve. And if your creatinine has been climbing and you’re not sure how to read it, what a high creatinine result means is a useful companion.
Where cell-based approaches fit, and where they don’t
People in stage 4 often ask about regenerative options, and that’s understandable when you’re hoping to hold onto what you have. The honest position is that this is an active area of research and results differ from person to person. Nobody can promise it will keep you off dialysis, and you should be wary of anyone who does. What’s reasonable is to understand what’s being studied, such as the role of stem cells in kidney disease, and to see how a provider talks about clinical evidence and safety before you decide anything. A good conversation starts with your actual lab history, not a brochure.
What to take to your next nephrology visit
Bring your last several eGFR results with dates, plus any urine protein results. Then ask the things you really want to know. How fast is my number moving? What would make you think I’m getting close? Am I a transplant candidate? Which dialysis type would suit my life? When should access surgery be planned? Write the answers down. You’ll forget half of them by the car park.
Frequently Asked Questions
Does eGFR 15 to 29 mean I need dialysis now?
No. Stage 4 usually means it’s time to plan. Dialysis is decided by your symptoms, blood chemistry and trend, not by one number.
At what eGFR do people usually start dialysis?
NIDDK says many people start when kidney function is between 5 and 10, once symptoms show up. It varies, and some start sooner or later.
How long can someone stay in stage 4?
It differs a lot. Some people remain stable for years, while others decline faster, especially if protein leakage or blood pressure is poorly controlled. Your own trend is the best guide.
Can I get on the transplant list during stage 4?
Possibly. NIDDK says a transplant centre can list you when your kidney function is 20 or less and the damage is permanent. You’d still need a full medical evaluation first.
When should the dialysis access be prepared?
Ideally well ahead of need, since vascular access surgery for hemodialysis and catheter placement for peritoneal dialysis both need healing time. Your nephrologist will say when.
Can I decide not to have dialysis?
Yes. Conservative management is a legitimate option, and the decision is yours. It should be an informed one, made with your doctor and family.
Can my eGFR go back up from stage 4?
Sometimes, if the drop had a temporary cause. Long-standing kidney damage rarely reverses, but progression can often be slowed.
Is dialysis permanent once I start?
Not always. NIDDK notes you can change or stop your treatment choice by talking with your care team, though for kidney failure that stops would have consequences, so it’s a conversation to have carefully.
Want a clearer picture of where you stand?
If you’re in stage 4 and want to talk through what your numbers might mean for your options, get in touch with the 23C Regen team and bring your recent results. If you’re travelling from overseas for a consultation, the details for international patients will save you a few emails.
This article is general information, not medical advice or a substitute for ordering tests through your own doctor. Consult with our team for proper assessment.