Posted on September 9, 2015
Review on lowering LDL-cholesterol in patients with chronic kidney disease, incorporating recently updated (inter)national lipid lowering and The Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guidelines
The review discussed a number of relevant topics and is largely based on available evidence for the three large RCT endpoint trials: SHARP (ezetimibe 10 mg + simvastatin 20 mg vs placebo); Aurora (rosuvastatin20 mg vs placebo) and the 4D study Atorvastatin 20 mg vs placebo). Topics reviewed are:
- patients with early stages of CKD: statins or statins + ezetimibe recommended
- Patients with advanced kidney disease: conflicting results. Patients on statins can continue but initiating treatment with statins or ezetimibe + statin is debatable.
- Kidney transplant recipients: Based on ALERT study, fluvastatin is recommended
- LDL-C level based statin initiation: KDIGO advises not to use LDL-C concentrations but absolute risk estimation
- Effect of statins on declining renal function: conflicting results; at this time Insufficient evidence to support the use of statins to slow down deteriorating renal function
- Effects of statins on albuminuria/proteinuria: No conclusive evidence on the effects of statins on protein-/albuminuria. Not harmful and perhaps beneficial
- Safety of statin: some conflicting reports from registry data vs RCT’s. KDIGO advices that the benefits outweigh the potential harms.
- Are all satins the same: Planet I and II studies showed favorable effects with Atorvastatin and harmful effect of rosuvastatin. In proteinuric diabetic and non-diabetic patients. Impossible ascertain whether this might reflect a protective effect of atorvastatin or a harmful effect of rosuvastatin
- New lipid lowering agents: no data available on patients with impaired renal function.
Statin therapy can be of benefit in CKD patients. The markedly increased CVD risk in this patient population can be reduced with appropriate management strategies and improving the lipid spectrum with statins plays a pivotal role. Uncertainties remain in patients with advanced organ damage and on dialysis.
“Current evidence provides convincing data that statin therapy reduces the risk of major CV events in patients with CKD across a broad range of kidney function with some uncertainty persisting for patients receiving dialysis.”
Management in CKD patients is still a conundrum with confusing data from observational studies and RCT’s . This review provides clinicians with a concise and up to date overview of relevant information on the use of statins in this challenging patient population
Lowering cholesterol in chronic kidney disease: is it safe and effective? Wong MG, Wanner C, Knight J, Perkovic V. Eur Heart J 2015; PMID: 26289904.