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

Management of Statins in Acute Kidney Injury (AKI)

Statins should generally be continued during episodes of acute kidney injury (AKI), except in cases of severe AKI where temporary discontinuation may be considered until renal function stabilizes. 1, 2

Evidence-Based Recommendations for Statin Management in AKI

Continue vs. Hold Decision Algorithm

• For patients already on statin therapy who develop AKI:

  • Continue statins in most cases of mild to moderate AKI 2
  • Consider temporarily holding statins only in cases of severe AKI with significant muscle injury risk or if the patient is hemodynamically unstable 3

• For patients not currently on statin therapy who develop AKI:

  • Do not initiate new statin therapy during an active AKI episode until renal function stabilizes 4

Statin Dosing Considerations in Kidney Disease

• Reduce doses of statins in patients with eGFR <60 mL/min/1.73 m² (avoid high-intensity statins) 1
• For specific statins:
  • Atorvastatin: No dose adjustment required for kidney disease 1
  • Rosuvastatin: No dose adjustment until creatinine clearance <30 mL/min/1.73 m² 1
  • Higher-potency statins (particularly high-dose simvastatin) should be used with caution as they are associated with increased AKI risk 5, 3

Benefits of Continuing Statins During AKI

• Continuing statins during AKI is associated with:
  • Lower mortality risk (hazard ratio 0.74; 95% CI 0.69-0.79) 2
  • Reduced all-cause rehospitalization rates (adjusted hazard ratio 0.90; 95% CI 0.85-0.94) 2
  • Lower levels of kidney injury biomarkers (IL-18, NGAL, KIM-1) compared to holding statins 6

Special Considerations

Dialysis Patients

• Do not initiate statins in patients requiring dialysis 1
• If a patient is already on statin therapy when initiating dialysis, continue the statin 1

Cardiac Surgery Patients

• High-dose perioperative statin therapy does not reduce AKI risk in cardiac surgery patients 4
• In statin-naïve patients with pre-existing CKD, high-dose perioperative statins may actually increase AKI risk 4

High-Risk Patients

• Use caution with high-potency statins (rosuvastatin, atorvastatin) in patients at high risk for AKI, as these are associated with 72-116% increased risk of AKI in both men and women 3
• A dose-effect relationship has been observed for rosuvastatin and atorvastatin regarding AKI risk 3

Monitoring Recommendations

• Monitor renal function more closely in patients continuing statins during AKI 1
• Consider checking creatine kinase levels if there are symptoms of myopathy 1
• Reassess the need for statin therapy periodically in patients with recurrent AKI episodes 1

Common Pitfalls to Avoid

• Avoid automatically discontinuing statins in all AKI cases, as this may increase mortality risk in patients who would benefit from continued therapy 2
• Avoid initiating high-potency statins during or immediately after an AKI episode 5, 3
• Do not confuse recommendations for AKI with those for chronic kidney disease or dialysis patients 1
• Remember that the risk-benefit ratio for statins changes with kidney function - benefits may be reduced in advanced kidney disease 1