From the Guidelines
Treat dyslipidemia in nephrotic syndrome when lipid levels remain persistently elevated despite management of the underlying kidney disease and reduction of proteinuria, with a focus on reducing the risk of atherosclerotic cardiovascular disease (ASCVD) rather than solely targeting specific lipid levels 1. The primary indication for treating hyperlipidemia in patients with nephrotic syndrome is to reduce the risk of ASCVD, which is elevated in these patients due to persistent dyslipidemia and other factors such as chronic inflammation and kidney dysfunction. Key considerations for initiating lipid-lowering therapy include:
- LDL cholesterol levels, but not as the sole determinant of treatment
- Non-HDL cholesterol levels
- Triglyceride levels
- Overall ASCVD risk, which can be estimated using various factors such as age, sex, blood pressure, and presence of other cardiovascular risk factors The first-line treatment for dyslipidemia in nephrotic syndrome is typically a statin, such as atorvastatin or rosuvastatin, which has been shown to reduce the risk of ASCVD in patients with kidney disease 1. For patients who cannot tolerate a statin or who are at high ASCVD risk and fail to achieve lipid goals despite maximally tolerated statin dose, consider adding non-statin therapy such as bile acid sequestrants, fibrates, or PCSK9 inhibitors 1. Regular monitoring of lipid levels and ASCVD risk factors is necessary to assess treatment efficacy and adjust therapy as needed, with a focus on reducing the risk of ASCVD rather than solely targeting specific lipid levels.
From the Research
Indications for Treating Hyperlipidemia in Nephrotic Syndrome
The treatment of hyperlipidemia in patients with Nephrotic Syndrome (NS) is crucial to prevent the progression of kidney disease and reduce the risk of cardiovascular complications. The following points highlight the indications for treating hyperlipidemia in NS:
- Hyperlipidemia is a common complication of NS, characterized by elevated levels of total cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides, which can lead to accelerated atherosclerosis and increased risk of cardiovascular disease 2, 3, 4.
- The European Society of Cardiology and European Atherosclerosis Society guidelines recommend the use of statins as first-line agents in the management of nephrotic dyslipidemia 2.
- Statins have been shown to be effective in reducing total cholesterol and LDL cholesterol levels in patients with NS, with some studies reporting significant increases in high-density lipoprotein (HDL) cholesterol levels 2, 5.
- Other lipid-lowering agents, such as bile acid sequestrants, fibrates, and nicotinic acid, may also be used in the treatment of hyperlipidemia in NS, although their efficacy and safety have not been extensively studied in this population 3, 4.
- The treatment of hyperlipidemia in NS may also involve dietary modifications, such as a low-fat, low-cholesterol diet, although this may not be sufficient to normalize cholesterol levels in most patients 5, 4.
Treatment Options
The following treatment options are available for hyperlipidemia in NS:
- Statins: effective in reducing total cholesterol and LDL cholesterol levels, with some studies reporting significant increases in HDL cholesterol levels 2, 5.
- Bile acid sequestrants: may be used in combination with statins or as an alternative therapy 3, 4.
- Fibrates: may be used to lower triglyceride levels, although they are not effective in lowering cholesterol levels 4.
- Nicotinic acid: may be used to lower cholesterol and triglyceride levels, although its efficacy and safety in NS have not been extensively studied 4.
- Ezetimibe: may be used in combination with statins or as an alternative therapy, although its efficacy and safety in NS have not been extensively studied 6.
- Lipid apheresis: may be used in patients with severe hyperlipidemia who are unresponsive to pharmacological therapy 6.