Can patients with End-Stage Renal Disease (ESRD) on Hemodialysis (HD) take statins?

Statins in ESRD Patients on Hemodialysis

Statins should not be initiated in patients with end-stage renal disease (ESRD) on hemodialysis, but should be continued if patients were already taking them before starting dialysis. 1, 2

Current Guideline Recommendations

The management of statins in ESRD patients on hemodialysis follows specific guidelines:

• For patients not currently on statins:

  • KDIGO guidelines provide a strong 2A recommendation against initiating statins or statin/ezetimibe combinations in dialysis-dependent CKD patients 1, 2
  • Multiple large randomized controlled trials (AURORA and 4D) have not shown a benefit of statin therapy in reducing cardiovascular events in hemodialysis patients 1
  • The SHARP trial showed a benefit of statin/ezetimibe therapy in the overall CKD population, but not in the subgroup of patients receiving dialysis 1

• For patients already on statins:

  • KDIGO suggests continuing statins or statin/ezetimibe combinations (Grade 2C recommendation) for patients who were already on statin therapy before initiating dialysis 1, 2
  • This recommendation is based on the fact that a significant percentage of patients in the SHARP trial reached ESRD and those randomly assigned to statin/ezetimibe had a benefit 1

Special Considerations

There are certain exceptions where initiating statins in dialysis patients might be considered:

1. Patients with recent acute coronary events who were typically excluded from clinical trials 1
2. Young patients on kidney transplant waiting lists with long life expectancy 1, 2
3. Patients with extremely high LDL cholesterol levels (≥190 mg/dL) 1

Safety Considerations

For patients continuing statins while on hemodialysis:

• Fluvastatin has no dose adjustment requirements for kidney disease 3
• Monitor for muscle symptoms (myalgia, weakness)
• Be vigilant for drug interactions, especially with medications commonly used in dialysis patients

Emerging Evidence

Some recent observational studies suggest potential benefits of statins in specific dialysis populations:

• A 2022 study found that statins were associated with reduced risk of cardiovascular death in ESRD patients following percutaneous coronary intervention 4
• A 2020 retrospective cohort study showed that patients who initiated statin therapy after starting hemodialysis or continued statins from pre-ESRD to post-ESRD had a lower risk of all-cause mortality 5

However, these observational findings do not override the recommendations from large randomized controlled trials and current guidelines.

Practical Algorithm for Decision-Making

1. Assess current statin status:

   • If patient is already on statin therapy before starting dialysis → Continue statin
   • If patient is not on statin therapy → Do not initiate statin unless they fall into one of the special consideration categories

2. For patients not on statins, check if they have any of these factors:

   • Recent acute coronary event
   • Young age with long life expectancy
   • On kidney transplant waiting list
   • LDL-C ≥ 190 mg/dL
   • If yes to any → Consider initiating statin therapy
   • If no to all → Do not initiate statin therapy

3. For patients continuing statins:

   • Monitor for muscle symptoms
   • Check for drug interactions
   • Periodically reassess risk-benefit ratio

This approach aligns with current guidelines while acknowledging the complexity of cardiovascular risk management in this high-risk population.