Is atorvastatin (Lipitor) better than rosuvastatin (Crestor) for patients with Chronic Kidney Disease (CKD)?

Atorvastatin vs. Rosuvastatin in Chronic Kidney Disease

Atorvastatin is preferred over rosuvastatin for patients with chronic kidney disease (CKD), particularly in those with eGFR <30 mL/min/1.73 m², due to its better safety profile and reduced risk of proteinuria, hematuria, and kidney function decline. 1

Evidence-Based Comparison

Safety Profile in CKD

• Atorvastatin requires no dose adjustment in patients with kidney disease 1
• Rosuvastatin should not exceed 10 mg daily when eGFR <30 mL/min/1.73 m² 1
• Rosuvastatin has been associated with higher rates of proteinuria and hematuria in CKD patients 1

Efficacy in CKD

• Both statins effectively lower LDL cholesterol in CKD patients
• The KDIGO guidelines recommend statin therapy for CKD patients with dose adjustments for reduced kidney function 2
• Atorvastatin has demonstrated cardiovascular risk reduction in CKD patients in the ALLIANCE study, with a 28% relative risk reduction compared to usual care 3

Dosing Recommendations by CKD Stage

eGFR (mL/min/1.73 m²)	Atorvastatin	Rosuvastatin
>60	20 mg daily (primary prevention)	Standard dosing
30-60	20 mg daily	Caution with doses >10 mg
<30	20 mg daily	Not recommended above 10 mg

Clinical Guidelines Support

The 2015 KDOQI US Commentary on KDIGO Guidelines recommends:

• For adults ≥50 years with eGFR <60 mL/min/1.73 m², treatment with a statin or statin/ezetimibe combination 2
• For adults ≥50 years with eGFR ≥60 mL/min/1.73 m², statin therapy is recommended 2
• For adults 18-49 years with CKD, statin therapy if they have coronary disease, diabetes, prior stroke, or elevated coronary risk 2

The NICE Guidelines specifically recommend:

• Atorvastatin 20 mg daily for both primary and secondary prevention in patients with CKD 2

Renal Function Impact

• Atorvastatin has shown no decrease in eGFR during long-term treatment in CKD patients 3
• Rosuvastatin has demonstrated some improvement in eGFR and reduction in proteinuria in certain studies 4, but concerns remain about its safety at higher doses in advanced CKD

Special Considerations

1. Advanced CKD (eGFR <30 mL/min/1.73 m²):

   • Atorvastatin is clearly preferred due to its safety profile 1
   • Rosuvastatin should be limited to ≤10 mg if used at all 1

2. Dialysis Patients:

   • Neither statin should be initiated in dialysis patients unless already on therapy when starting dialysis 2, 1
   • The 4D trial showed atorvastatin did not improve cardiovascular outcomes in hemodialysis patients with type 2 diabetes 2

3. Drug Interactions:

   • Atorvastatin has more potential drug interactions than rosuvastatin due to CYP3A4 metabolism
   • This is particularly important in CKD patients who often take multiple medications

Common Pitfalls to Avoid

1. Initiating high-dose statins in severe CKD without monitoring

   • Start with lower doses and monitor for side effects, especially with rosuvastatin

2. Overlooking proteinuria monitoring

   • Regular urinalysis is important, especially with rosuvastatin which has higher risk of proteinuria

3. Focusing solely on LDL reduction

   • Consider overall cardiovascular risk reduction and kidney function preservation

4. Starting statins in dialysis patients

   • Guidelines recommend against initiating statins in dialysis patients 2, 1

In conclusion, while both statins can effectively lower cholesterol in CKD patients, atorvastatin offers a more favorable safety profile, particularly in advanced CKD, and is the preferred agent according to current guidelines.