From the Guidelines
Atorvastatin can be administered in patients with acute on chronic kidney disease (CKD), but caution is warranted, particularly in those with significant renal impairment or other risk factors for statin-related myopathy. For patients already on atorvastatin, it's typically reasonable to continue the medication during an acute kidney injury episode superimposed on chronic kidney disease, as the benefits of cardiovascular risk reduction often outweigh the risks, as supported by the Study of Heart and Renal Protection (SHARP) trial 1. However, for those not previously on a statin, initiation during acute kidney injury should be deferred until renal function stabilizes unless there are compelling cardiovascular indications, such as a high risk of major cardiovascular events, as suggested by the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1. Atorvastatin undergoes hepatic metabolism with minimal renal excretion, making it one of the preferred statins in kidney disease, as noted in the prevention and treatment of stroke in patients with chronic kidney disease guidelines 1. No dose adjustment is typically required for renal impairment alone, but patients with kidney disease may have an increased risk of statin-related myopathy, so monitoring for muscle symptoms is important, as recommended by the Kidney Disease: Improving Global Outcomes Lipid Work Group 1. Starting at lower doses (10-20mg daily) may be prudent, with careful titration based on tolerance and lipid response. Regular monitoring of renal function, liver enzymes, and creatine kinase (if muscle symptoms develop) is recommended during therapy. Key considerations include:
- The potential benefits of atorvastatin for cardiovascular risk reduction in patients with CKD, as supported by the SHARP trial 1
- The increased risk of statin-related myopathy in patients with kidney disease, as noted by the Kidney Disease: Improving Global Outcomes Lipid Work Group 1
- The importance of monitoring renal function, liver enzymes, and creatine kinase during therapy, as recommended by the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1.
From the FDA Drug Label
Risk factors for myopathy include age 65 years or greater, uncontrolled hypothyroidism, renal impairment, concomitant use with certain other drugs (including other lipid-lowering therapies), and higher atorvastatin calcium dosage [see Drug Interactions (7.1) and Use in Specific Populations ( 8.5,8. 6)]. Temporarily discontinue atorvastatin calcium tablets in patients experiencing an acute or serious condition at high risk of developing renal failure secondary to rhabdomyolysis (e.g., sepsis; shock; severe hypovolemia; major surgery; trauma; severe metabolic, endocrine, or electrolyte disorders; or uncontrolled epilepsy).
Atorvastatin can be administered in patients with acute on chronic kidney disease (CKD), but with caution. Renal impairment is a risk factor for myopathy, and atorvastatin calcium dosage modifications are recommended for patients with renal impairment. Additionally, atorvastatin calcium tablets should be temporarily discontinued in patients experiencing an acute or serious condition at high risk of developing renal failure secondary to rhabdomyolysis 2, 2, 2.
From the Research
Administration of Atorvastatin in Patients with Acute on Chronic Kidney Disease (CKD)
- Atorvastatin, a HMG-CoA reductase inhibitor, can be administered in patients with acute on chronic kidney disease (CKD) as it does not require dose adjustments based on renal function 3.
- Statins, including atorvastatin, are the first-line lipid-lowering therapy in patients with CKD and cardiovascular disease (CVD) 3.
- The use of atorvastatin in patients with CKD has been shown to improve endothelial function, reduce oxidative stress, and suppress inflammation 4.
- However, careful monitoring of renal function is essential when initiating or continuing atorvastatin therapy in patients with CKD, especially those with severe renal impairment 5.
Considerations for Atorvastatin Use in CKD Patients
- Patients with CKD should be treated early and intensively with lipid-lowering therapy to minimize their high risk of cardiovascular events and possibly slow the progression of CKD 3.
- Atorvastatin can be used in combination with other lipid-lowering agents, such as ezetimibe, to achieve optimal lipid profiles in patients with CKD 3, 4.
- The safety and efficacy of atorvastatin in patients with end-stage renal disease (ESRD) or those undergoing dialysis are not well established and require further investigation 6, 5.