Current Hypertension Management

In Daily Practice

PRANAWA
DIVISION
DIVISION OF
OF NEPHROLOGY
NEPHROLOGY AND
AND HYPERTENSION
HYPERTENSION
DEPT.
DEPT. OF
OF INTERNAL
INTERNAL MEDICINE
MEDICINE FACULTY
FACULTY OF
OF MEDICINE
MEDICINE AIRLANGGA
AIRLANGGA UNIVERSITY
UNIVERSITY
DR.
DR. SOETOMO
SOETOMO HOSPITAL
HOSPITAL
SURABAYA
SURABAYA

Blood Pressure Assessment:

Patient preparation and posture
Standardized Preparation:
Patient
1. No acute anxiety, stress or pain.
2. No caffeine, smoking or nicotine in the preceding
30 minutes.
3. No use of substances containing adrenergic
stimulants such as phenylephrine or
pseudoephedrine (may be present in nasal
decongestants or ophthalmic drops).
4. Bladder and bowel comfortable.
5. No tight clothing on arm or forearm.
6. Quiet room with comfortable temperature
7. Rest for at least 5 minutes before measurement
8. Patient should stay silent prior and during the
procedure.

Blood Pressure Assessment:

Patient preparation and posture
Standardized technique:
Posture
The patient should be
calmly seated with his
or her back well
supported and arm
supported at the level of
the heart.
His or her feet should
touch the floor and legs
should not be crossed.

Blood Pressure Assessment:

Patient position

Recommended Technique
for Measuring Blood Pressure* (cont.)
Drop pressure by 2 mmHg / beat
Appearance of sound (phase I
Korotkoff) = systolic pressure

Drop pressure by 2 mmHg / beat

Disappearance of sound (phase
V Korotkoff) = diastolic pressure

Record measurement
Take at least 2 blood pressure
measurements, 1 minute apart

*with manual or semi automated devices

Korotkoff sounds and auscultatory gaps

Korotkoff sounds
200
180

No sound
Clear sound

Phase 1

Muffling

Phase 2

140

No sound

Auscultatory
gap

120

Clear sound

Phase 3

160

100

Muffled sound

Phase 4

No sound

Phase 5

80
60
40
20
0
mmHg

Systolic BP

Phase 3
Phase 4
Diastolic BP

Definition and classification of

hypertension: JNC VII
Hypertension is defined as blood pressure 140/90 mmHg
Category

Systolic

Diastolic

(mmHg)

(mmHg)

<120

and <80

Prehypertension

120-139

or 80-89

Stage 1 hypertension

140-159

or 90-99

Stage 2 hypertension

160

or 100

Normal

JNC VII. JAMA 2003;289:2560-2572

Definition and classification of

hypertension: WHO/ISH 1999/2003
Hypertension is defined as blood pressure 140/90 mmHg
Category

Systolic

Diastolic

(mmHg)

(mmHg)

Optimal

<120

<80

Normal

<130

<85

High-normal

130-139

85-89

Grade 1 hypertension (mild)

140-159

or 90-99

140-149

90-94

160-179

or 100-109

Grade 3 hypertension (severe)

180

or 110

Isolated systolic hypertension

140

<90

140-149

<90

Subgroup: borderline
Grade 2 hypertension (moderate)

Subgroup: borderline
When a patients systolic and diastolic blood pressures fall
into different categories, the higher category should apply

2003 WHO/ISH Statement on Hypertension.

J Hypertens 2003;21:1983-1992; 1999 WHO/ISH Guidelines for the
Management of Hypertension. J Hypertens 1999;17:151-183

III. Assessment of the overall cardiovascular risk

Search for target organ damage

Cerebrovascular disease

Hypertensive retinopathy
Left ventricular dysfunction
Left ventricular hypertrophy
Coronary artery disease

myocardial infarction
angina pectoris
congestive heart failure

Chronic kidney disease

transient ischemic attacks

ischemic or hemorrhagic stroke
vascular dementia

hypertensive nephropathy
(GFR < 60 ml/min/1.73 m2)
albuminuria

Peripheral artery disease

intermittent claudication
ankle brachial index < 0.9

III. Assessment of the overall cardiovascular

risk
Search for exogenous potentially modifiable factors that can
induce/aggravate hypertension
Prescription Drugs:

NSAIDs, including coxibs

Corticosteroids and anabolic steroids
Oral contraceptive and sex hormones
Vasoconstricting/sympathomimetic decongestants
Calcineurin inhibitors (cyclosporin, tacrolimus)
Erythropoietin and analogues
Antidepressants: Monoamine oxidase inhibitors (MAOIs), SNRIs, SSRIs
Midodrine

Other:

Licorice root
Stimulants including cocaine
Salt
Excessive alcohol use

CVD Risk Factors

Hypertension*
Cigarette smoking
Obesity* (BMI >30 kg/m2)
Physical inactivity
Dyslipidemia*
Diabetes mellitus*
Microalbuminuria or estimated GFR <60 ml/min
Age (older than 55 for men, 65 for women)
Family history of premature CVD
(men under age 55 or women under age 65)
*Components of the metabolic syndrome.

Target Organ Damage

Heart
Left ventricular hypertrophy
Angina or prior myocardial infarction
Prior coronary revascularization
Heart failure
Brain
Stroke or transient ischemic attack
Chronic kidney disease
Peripheral arterial disease
Retinopathy

Cardiovascular Risk
Click to edit Master title style
Stratification

Blood pressure (mm Hg)

Other risk factor,

organ damage, or
disease

Normal

High
normal

No other risk
factors

Average
risk

Average
risk

1-2 risk factors

Low
added
risk

Low
added
risk

3 risk factors,
mets, organ
damage, or
diabetes

Moderate
added
risk

High
added
risk

High
added
risk

High
added
risk

Very high
added risk

Established CV or
renal disease

Very high
added
risk

Very high
added
risk

Very high
added
risk

Very high
added
risk

Very high
added risk

Grade 1
HT

Grade 2
HT

Low
Moderate
added
added
risk
risk
Moderate Moderate
added
added
risk
risk

Grade 3
HT
High
added risk
Very high
added risk

HT: hypertension; mets: metabolic syndrome; CV: cardiovascular

Mancia G, et al. 2007 ESH/ESC Guidelines for the Management of Arterial Hypertension. J Hypertens 2007;25:1105-1187

Stratication of CV Risk in four categories

Click to edit Master title style

Blood Pressure (mmHg)

Other risk
factors, OD, or
disease

Normal SBP
120129
and/or
DBP 8084

No other risk
factors,

Average risk

1-2 risk factors

Low added
risk

3 or more risk
factors, MS, OD,
or diabetes

Moderate
added risk

Established CV
or renal disease

Very high
added risk

High normal
SBP 130139
and/or
DBP 8589

Grade 1 HT
SBP 140159
and/or
DBP 9099

Grade 2 HT
SBP 160179
and/or
DBP 100109

Grade 3 HT
SBP >180
and/or
DBP >110

Average risk

Low added
risk

Moderate
added risk

High added
risk

Low added
risk

Moderate
added risk

Moderate
added risk

Very high
added risk

High added
risk

High added
risk

High added
risk

Very high
added risk

Very high
added risk

Very high
added risk

Very high
added risk
Very high
added risk

Stratication of CV Risk in four categories. SBP: systolic blood pressure; DBP: diastolic blood pressure; CV: cardiovascular; HT: hypertension.
Low, moderate, high and very high risk refer to 10 year risk of a CV fatal or non-fatal event. The term added indicates that in all categories risk
is greater than average. OD: subclinical organ damage; MS: metabolic syndrome. The dashed line indicates how denition of hypertension
may be variable, depending on the level of total CV risk.

Initiation
of antihypertensive
treatment
Click to edit
Master title style
Blood Pressure (mmHg)
Other risk
factors, OD, or
disease
No other risk
factors,

Normal SBP
120129
and/or
DBP 8084
No BP intervention

High normal
SBP 130139
and/or
DBP 8084

Grade 1 HT
SBP 140159
and/or
DBP 9099

Grade 2 HT
SBP 160179
and/or
DBP 100109

Grade 3 HT
SBP >180
and/or
DBP >110

No BP intervention

Lifestyle changes for

several months then
drug treatment if BP
uncontrolled

Lifestyle changes for

several weeks then
drug treatment if BP
uncontrolled

Lifestyle changes
+
Immediate drug
treatment

Lifestyle changes for

several weeks then
drug treatment if BP
uncontrolled

Lifestyle changes for

several weeks then
drug treatment if BP
uncontrolled

Lifestyle changes
+
Immediate drug
treatment

Lifestyle changes
+
Drug treatment

Lifestyle changes
+
Drug treatment

Lifestyle changes
+
Immediate drug
treatment

Lifestyle changes
+
Immediate drug
treatment

Lifestyle changes
+
Immediate drug
treatment

Lifestyle changes
+
Immediate drug
treatment

1-2 risk factors

Lifestyle changes

Lifestyle changes

> 3 risk factors,

MS or OD

Lifestyle changes

Lifestyle changes
and consider
drug treatment

Diabetes

Lifestyle changes

Lifestyle changes +
drug treatment

Established CV
or renal
disease

Lifestyle changes
+
Immediate drug
treatment

Lifestyle changes
+
Immediate drug
treatment

Current to
Blood
Pressure
Targets
Various Chronic Conditions
Click
edit
Master
titleforstyle

Uncomplicated
Hypertension

Chronic Kidney Disease

Coronary Artery Disease
Diabetes

140
90

130
80

Systolic
Blood
Pressure
Diastolic
Blood
Pressure

mm Hg

American Diabetes Association. Diabetes Care. 2003;26:S80-S82;

Hansson L, et al. Lancet. 1998;351:1755-1762; National Kidney
Foundation. Am J Kidney Dis. 2002;39(2 Suppl 1):S1-S266;
Rosendorff C, et al. Circulation. 2007;115:2761-2788.

Slide Source
Hypertension Online
www.hypertensiononline.org

V. Goals of Therapy
2012 Canadian Hypertension
Education Program
Recommendations

V. Goals of Therapy
Blood pressure target values for treatment of hypertension
Condition
Target
SBP and DBP mmHg
Isolated systolic hypertension

<140

Systolic/Diastolic Hypertension
Systolic BP
Diastolic BP

<140
<90

Diabetes
Systolic
Diastolic

<130
<80

Non-DM CKD
Systolic
Diastolic

<140
<90
18

Laboratory Tests
Routine Tests
Electrocardiogram
Urinalysis
Blood glucose, and hematocrit
Serum potassium, creatinine, or the corresponding estimated GFR,
and calcium
Lipid profile, after 9- to 12-hour fast, that includes high-density and
low-density lipoprotein cholesterol, and triglycerides
Optional tests
Measurement of urinary albumin excretion or albumin/creatinine ratio
More extensive testing for identifiable causes is not generally indicated
unless BP control is not achieved

IV. Routine Laboratory Tests

Preliminary Investigations of patients with hypertension
1.
2.
3.
4.

Urinalysis
Blood chemistry (potassium, sodium and creatinine)
Fasting glucose
Fasting total cholesterol and high density lipoprotein
cholesterol (HDL), low density lipoprotein cholesterol (LDL),
triglycerides
5. Standard 12-leads ECG

Currently there is insufficient evidence to recommend routine

testing of microalbuminuria in people with hypertension who
do not have diabetes

Modifikasi gaya hidup untuk

pengendalian
Hipertensi
Click to edit Master
title style
Modifikasi

Rekomendasi

Penurunan Tekanan
Darah Sistolik kurang
lebih

Menurunkan
berat badan

Pelihara berat badan

normal (BMI 18.5-24.9)

5-20 mm Hg utk
setiap penurunan 10
kg BB

Menjalankan
menu DASH

Konsumsi makanan kaya

buah, sayur, susu
rendah lemak dan
rendah lemak jenuh

8-14 mm Hg

Mengurangi
asupan
garam/sodium
Meningkatkan
aktifitas fisik

Kurangi natrium sampai

tidak lebih dari 2.4
g/hari atau NaCl 6
g/hari

2-8 mm Hg

Berolahraga erobik
4-9 mm Hg
teratur seperti misalnya
berjalan kaki
(30 men/hari 4-5 hari
Source: Theseminggu)
Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:2560-2572.

Batasi konsumsi

2-4 mm Hg

Lifestyle Recommendations for Hypertension:

Dietary
Dietary Sodium

High in:
Fresh fruits
Fresh vegetables
Low fat dairy products
Dietary and soluble fibre
Plant protein

Low in:
Saturated fat and cholesterol
Sodium

Less than 2300mg / day

(Most of the salt in food is hidden and comes
from processed food)

Dietary Potassium
Daily dietary intake >80 mmol

Calcium supplementation
No conclusive studies for hypertension

Magnesium supplementation
No conclusive studies for hypertension
www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php.

Recommendations for adequate daily sodium intake

Age

Adequate
Intake
(mg)

Upper
Limit
(mg)

19-50

1500

2300

51-70

1300

2300

71 and
over

1200

2300

2,300 mg sodium (Na)

= 100 mmol sodium (Na)
= 5.8 g of salt (NaCl)
= 1 level teaspoon of
table salt

80% of average sodium intake is in processed foods

Only 10% is added at the table or in cooking
Institute of Medicine, 2003

Compelling Indications for Individual Drug

Classes
Click to edit Master title style
JNC-7

JNC VII :
algorithm for treatment of hypertension
Lifestyle modifications
Not at goal BP*
HTN without compelling
indications

Stage 1

Stage 2

Thiazide-type diuretics
for most. May consider
ACE inhibitor, ARB, blocker, CCB, or
combination

Two-drug combination
for most (usually
including thiazide-type
diuretic)

HTN with compelling

indications
Drug(s) for the
compelling indications
Other antihypertensive
drugs (diuretics, ACE
inhibitor, ARB, -blocker,
CCB) as needed

If not at goal, optimise dosages or add additional drugs until goal BP is achieved.
Consider consultation with hypertension specialist
*BP goal <140/90 mmHg or <130/80 mmHg for those
with diabetes or chronic kidney disease

Chobanian et al. JAMA 2003;289:256072

Hypertension management guidelines

recommend combination therapy for high
CV risk patients
Mild BP elevation
Low/moderate CV risk
Conventional BP target

Choose between

Marked BP elevation
High/very high CV risk
Lower BP target

2-drug combination
at low dose

Single agent at low dose

If target BP not achieved

Previous agent
at full dose

Switch to different
agent at low dose

Previous
combination
at full dose

Add a 3rd drug

at low dose

If target BP not achieved

23 drug
combination
at full dose

Full dose
monotherapy

Reproduced with permission from: Mancia G, et al. J Hypertens 2007;25:110587

23 drug
combination at full
dose

Aged under
55 years

Aged over 55 years

or black person of
African or Caribbean
family origin of any
age
C2

Summary of
antihypertensive
drug treatment
Step 1

A + C2

Step 2

A+ C + D

Step 3

Resistant hypertension

Step 4

Key
A ACE inhibitor or low-cost
angiotensin II receptor
blocker (ARB)1
C Calcium-channel blocker
(CCB)
D Thiazide-like diuretic

A + C + D + consider further
diuretic3, 4 or alpha- or
beta-blocker5
Consider seeking expert advice

See slide notes for details of

footnotes 1-5

II. Indications for Pharmacotherapy

Usual blood pressure threshold values for initiation of pharmacological treatment of hypertension

* lifestyle modification is recommended for all

regardless of BP

General population (including

CKD) (CHEP 2011**)
Very elderly (>80) (CHEP

140/90
150

2013**)

Diabetes

(CHEP 2000**)

130/80

** Year of incorporation into CHEP recommendations

III. Treatment of Adults with Systolic/Diastolic

Hypertension without Other Compelling Indications
TARGET <140/90 mmHg
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification
therapy

Thiazide

ACEI

ARB

Longacting
CCB

Betablocker*

A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20
mmHg systolic or >10 mmHg diastolic above target
*BBs are not indicated as first line therapy for age 60 and above

ACEI, ARB and direct renin inhibitors are contraindicated in pregnancy and caution is required in
prescribing to women of child bearing potential

III. Summary: Treatment of Systolic-Diastolic

Hypertension without Other Compelling Indications
TARGET <140/90 mmHg
Lifestyle modification

Initial therapy

Thiazide
diuretic

CONSIDER
Nonadherence
Secondary HTN
Interfering drugs or
lifestyle
White coat effect

ACEI

ARB

Long-acting
CCB

A combination of 2 first line drugs may

be considered as initial therapy if the
blood pressure is >20 mmHg systolic
or >10 mmHg diastolic above target

Betablocker*

Dual Combination

Triple or Quadruple
Therapy

*Not indicated as first

line therapy over 60 y

DEFINITION

Definition of Chronic Kidney Disease

Criteria
1. Kidney damage for > 3 months, as defined by structural or
functional abnormalities of the kidney, with or without decreased
GFR, manifest by either :
Pathological abnormalities; or
Markers of kidney damage, including abnormalities in the
composition of the blood or urine, or abnormalities in
imaging tests
2. GFR < 60 mL/min/1.73 m for > 3 months, with or without kidney
damage
GFR = glomerular filtration rate

National Kidney Foundation. K/DOQI Crinical Practice Guidelines for Chronic Kidney Disease:
Executive Summary. New York, 2002; p. 6

Stages of Chronic Kidney Disease

Stage

Description

GFR
(mL/min/1.73 m2)

> 90

Kidney damage with normal or

GFR
Kidney damage with mild GFR

60 89

Moderate GFR

30 59

Severe GFR

15 29

Kidney failure

< 15 or dialysis

Chronic kidney disease is defined as either kidney damage or GFR <

60 mL/min/1.73 m2 for > 3 months. Kidney damage is defined as
pathologic abnormalities or markers of damage, including
abnormalities in blood or urine tests or imaging studies
National Kidney Foundation. K/DOQI Crinical Practice Guidelines for Chronic Kidney Disease:
Executive Summary. New York, 2002

Stages in Progression of
Chronic Kidney Disease and Therapeutic Strategies
Complications
Complications

Normal
Normal

Increased
Increased
Risk
Risk

Damage
Damage

GFR
GFR

Screening
Screening for
for
CKD
CKD risk
risk
factors
factors

CKD
CKD risk
risk
reduction,
reduction,
Screening
Screening for
for
CKD
CKD

Diagnosis
Diagnosis &&
treatment,
treatment,
Treat
Treat
comorbid
comorbid
conditions,
conditions,
Slow
Slow
progression
progression

Estimate
Estimate
progression,
progression,
Treat
Treat
complications,
complications,
Prepare
Prepare for
for
replacement
replacement

Kidney
Kidney
failure
failure

CKD
CKD
death
death

Replacement
Replacement
by
by dialysis
dialysis &&
transplant
transplant

National Kidney Foundation. K/DOQI Crinical Practice Guidelines for Chronic Kidney Disease:
Executive Summary. New York, 2002; p. 9

Evaluation of Proteinuria in Patients Not Known to Have Kidney Disease

Evaluation
Evaluation for
for proteinuria
proteinuria
Not
Not at
at risk
risk
Standard
Standard dipstick
dipstick
>1+
>1+

At
At risk
risk
Albumin-specific-dipstick
Albumin-specific-dipstick

Negative/trace
Negative/trace

Positive
Positive

Negative
Negative

Total
Total protein/creatinine
protein/creatinine ratio
ratio
>200mg/g
>200mg/g

Albumin/creatinine
Albumin/creatinine ratio
ratio

<200mg/g
<200mg/g

<30mg/g
<30mg/g

>30mg/g
>30mg/g

Recheck
Recheck at
at periodic
periodic
health
health evaluation
evaluation
Diagnostic
Diagnostic evaluation
evaluation
Treatment
Treatment

Consultation
Consultation

National Kidney Foundation. K/DOQI Crinical Practice Guidelines for Chronic Kidney Disease:
Executive Summary. New York, 2002; p. 40

INTERVENTION TO SLOW THE PROGRESSION

OF KIDNEY DISEASE
(K/DOQI
(K/DOQI Guidelines
Guidelines 2002)
2002)

Have been proven to be effective :

Strict glucose control in diabetes
Strict blood pressure control
RAA system blockade
Have been studied, inconclusive result :
Dietary protein restriction
Lipid-lowering therapy
Partial correction of anemia

Adapted from Sraer JD et al. Role of the renin-angiotensin system in the regulation of glomerular filtration. J Cardiovasc
Pharmacol 1989;14.Suppl.4:S21-5.

Adapted from Sraer JD et al. Role of the renin-angiotensin system in the regulation of glomerular filtration. J Cardiovasc
Pharmacol 1989;14.Suppl.4:S21-5.

Adapted from Sraer JD et al. Role of the renin-angiotensin system in the regulation of glomerular filtration. J Cardiovasc
Pharmacol 1989;14.Suppl.4:S21-5.

Whats New for 2009

The combination of an ACE inhibitor with an ARB
is not recommended in patients with
hypertension without compelling indications,
coronary artery disease who do not have heart
failure,
prior stroke,
non proteinuric chronic kidney disease or
diabetes mellitus without micro albuminuria

N Engl J Med 2008;358:1547-59

Lancet 2008; 372: 54753
2009 Canadian Hypertension Education Program Recommendations

39

Whats New for 2009

The use of combination of ACE

inhibitor with an ARB should only be
considered in selected and closely
monitored people with advanced
heart failure or proteinuric
nephropathy.

2009 Canadian Hypertension Education Program Recommendations

40

Additional Factors in Progression

of Chronic Kidney Disease
Alcohol and recreational drugs
NSAIDs
Lead and heavy metals exposure

Other Measures to Retard Progression

of Chronic Kidney Disease (1)
Avoid multiple daily doses of acetaminophen,
Avoid NSAIDs
Avoid herbal therapy unless the safety of the
herb has been proved.
Avoid prolonged severe hypokalemia
because it can cause progressive renal
interstitial fibrosis.
Avoid phosphate cathartics. These can cause
acute kidney injury (AKI) and CKD by causing
intratubular calcium phosphate deposits.

KDIGO 2012 Clinical Practice Guideline

for the Evaluation and Management of
Chronic Kidney Disease

3.1 PREVENTION OF CKD PROGRESSION

BP and RAAS interruption
3.1.1 Individualize BP targets and agents according to age,
coexistent cardiovascular disease and other comorbidities, risk
of progression of CKD, presence or absence of retinopathy (in
CKD patients with diabetes), and tolerance of treatment as
described in the KDIGO 2012 Blood Pressure Guideline. (Not
Graded)
3.1.2 Inquire about postural dizziness and check for postural
hypotension regularly when treating CKD patients with BPlowering drugs. (Not Graded)
3.1.3 Tailor BP treatment regimens in elderly patients with
CKD by carefully considering age, comorbidities and other
therapies, with gradual escalation of treatment and close
attention to adverse events related to BP treatment, including
electrolyte disorders, acute deterioration in kidney function,
orthostatic hypotension and drug side effects. (Not Graded)

4.4 MEDICATION MANAGEMENT AND

PATIENT SAFETY IN CKD
4.4.1 We recommend that prescribers should take GFR into
account when drug dosing. (1A)
4.4.2 Where precision is required for dosing (due to narrow
therapeutic or toxic range) and/or estimates may be
unreliable (e.g., due to low muscle mass), we recommend
methods based upon cystatin C or direct measurement of
GFR. (1C)
4.4.3 We recommend temporary discontinuation of
potentially nephrotoxic and renally excreted drugs in
people with a GFR <60 ml/min/1.73 m2 (GFR categories
G3a-G5) who have serious intercurrent illness that
increases the risk of AKI. These agents include, but are not
limited to: RAAS blockers (including ACE-Is, ARBs,
aldosterone inhibitors, direct renin inhibitors), diuretics,
NSAIDs, metformin, lithium, and digoxin. (1C)

4.4.4 We recommend that adults with CKD seek medical

or pharmacist advice before using over-the-counter
medicines or nutritional protein supplements. (1B)
4.4.5 We recommend not using herbal remedies in
people with CKD. (1B)
4.4.6 We recommend that metformin be continued in people
with GFR 45 ml/min/1.73 m2 (GFR categories G1-G3a); its use
should be reviewed in those with GFR 3044 ml/min/1.73 m2
(GFR category G3b); and it should be discontinued in people
with GFR <30 ml/min/1.73 m2 (GFR categories G4-G5). (1C)
4.4.7 We recommend that all people taking potentially
nephrotoxic agents such as lithium and calcineurin inhibitors
should have their GFR, electrolytes and drug levels regularly
monitored. (1A)
4.4.8 People with CKD should not be denied therapies for other
conditions such as cancer but there should be appropriate
dose adjustment of cytotoxic drugs according to knowledge of
GFR. (Not Graded)

Other Measures to Retard Progression

of Chronic Kidney Disease (2)
Avoid intravenous bisphosphonates in CKD.
Some may exacerbate renal failure.
Avoid oral estrogen in elderly women with
CKD. It may promote progression.
NaHCO3 to correct metabolic acidosis should
be considered because of its anticatabolic
effects.
Control hyperphosphatemia and
hyperparathyroidism.