Should statins be held in patients with Acute Kidney Injury (AKI)?

Management of Statins in Acute Kidney Injury

Statins should be temporarily held in patients with acute kidney injury (AKI) to prevent worsening renal function and potential statin-induced myopathy.

Rationale for Holding Statins in AKI

• It is not recommended to initiate statin therapy shortly before elective cardiac surgery with cardiopulmonary bypass due to the associated risk of AKI 1
• High-dose perioperative atorvastatin treatment compared with placebo did not reduce the risk of AKI overall, among patients naive to treatment with statins, or in patients already taking a statin 2
• High-potency statins are associated with an increased risk of acute kidney injury compared with low-potency statins in the first 6 months after starting therapy 3
• Patients with chronic kidney disease (CKD) receiving atorvastatin had increased AKI risk, with the data and safety monitoring board recommending stopping statin treatment in this population 2

Considerations for Continuing Statins

• It should be considered to continue statin therapy at the current dose during cardiac surgery with cardiopulmonary bypass 1
• In patients already taking statins or statin/ezetimibe combination at the time of dialysis initiation, it is suggested that these agents be continued 1
• Continuing (vs holding) a statin before cardiac operation was associated with a lower risk of elevation of AKI biomarkers, suggesting potential protective effects in patients already on statin therapy 4

Monitoring During AKI

• If myositis is present or strongly suspected during AKI, the statin should be discontinued immediately 1
• Obtain a creatine kinase (CK) measurement if the patient reports suggestive muscle symptoms, and compare to CK blood level prior to beginning therapy 1
• If the patient experiences muscle soreness, tenderness, or pain with CK greater than 10 times the upper limit of normal (ULN), discontinue statin therapy 1
• For patients with muscle symptoms and moderate CK elevation (3-10 times ULN), follow symptoms and CK levels weekly until there is no longer medical concern 1

Restarting Statins After AKI Resolution

• After discontinuation of statins due to AKI, wait for symptoms to resolve and CK levels to return to normal before reinitiating therapy 1
• Use a lower dose of the statin if possible when restarting 1
• Consider using a statin with lower myopathy risk if statin therapy is attempted again after an AKI episode 5
• Avoid concomitant medications that interact with statins when restarting therapy 5

Special Populations

• For patients with end-stage kidney disease on dialysis, statins should not be initiated but should be continued if the patient is already treated 1
• In patients with CKD not on dialysis, statins are generally recommended for cardiovascular risk reduction, but should be temporarily held during AKI episodes 1
• Patients with recent acute coronary syndrome may benefit from continuing statin therapy despite AKI, as high-potency statin regimens did not increase the risk of kidney injury in this population 6

Preventive Strategies

• Statin pretreatment may be effective at preventing contrast-induced AKI in patients with preexisting renal insufficiency 7
• Regular monitoring of CK levels is recommended if statin therapy is reinitiated after an AKI episode, especially during the first few months 5
• Educate patients to report muscle symptoms promptly if they recur after restarting statin therapy 5

In conclusion, the evidence supports temporarily holding statins during AKI episodes, particularly in statin-naive patients, while continuing therapy may be appropriate in those already established on statins depending on the clinical context and severity of the AKI.