What statin (HMG-CoA reductase inhibitor) is recommended for patients with chronic kidney disease (CKD)?

Statin Therapy for Patients with Chronic Kidney Disease

For patients with chronic kidney disease (CKD), statin or statin/ezetimibe combination therapy is recommended, with specific regimens based on CKD stage and patient age. 1

Recommendations Based on CKD Stage

Non-Dialysis Dependent CKD (Stages G3a-G5)

• For adults ≥50 years with eGFR <60 ml/min/1.73 m² not on dialysis, a statin or statin/ezetimibe combination is strongly recommended (Grade 1A recommendation) 1
• This recommendation is based on the SHARP trial, which demonstrated that simvastatin-ezetimibe combination therapy reduced major atherosclerotic events in this population 1
• Statins reduce relative risk of cardiovascular events similarly in patients with and without CKD, but the absolute benefit is larger in CKD patients due to their higher baseline cardiovascular risk 1

Early CKD (Stages G1-G2)

• For adults ≥50 years with CKD and eGFR ≥60 ml/min/1.73 m² (stages G1-G2), statin monotherapy is recommended (Grade 1B recommendation) 1
• Most patients with early CKD have albuminuria with normal or slightly reduced eGFR and benefit from statin therapy similar to the general population 1

Younger Patients with CKD (18-49 years)

• For adults 18-49 years with CKD not on dialysis, statin therapy is suggested (Grade 2A recommendation) if they have one or more of: 1
  • Known coronary disease (myocardial infarction or coronary revascularization)
  • Diabetes mellitus
  • Prior ischemic stroke
  • Estimated 10-year incidence of coronary death or non-fatal MI >10%

Dialysis-Dependent CKD

• For patients with dialysis-dependent CKD and no atherosclerotic cardiovascular disease, statins should NOT be initiated (Grade 3A recommendation) 1
• This is based on evidence from the 4D study and AURORA trial showing no significant benefit of statins on cardiovascular outcomes in dialysis patients 1
• However, in patients already on statins at the time of dialysis initiation, these drugs should be continued, particularly in those with cardiovascular disease 1

Specific Statin Selection and Dosing

The KDIGO guidelines recommend specific statin regimens based on kidney function:

• For patients with eGFR ≥60 ml/min/1.73 m²: 1

  • Atorvastatin (10-80 mg)
  • Fluvastatin (40-80 mg)
  • Lovastatin (40 mg)
  • Pravastatin (40 mg)
  • Rosuvastatin (5-40 mg)
  • Simvastatin (20-40 mg)

• For patients with eGFR <60 ml/min/1.73 m² (not on dialysis): 1

  • Atorvastatin (10-80 mg)
  • Fluvastatin (40-80 mg)
  • Lovastatin (40 mg)
  • Pravastatin (40 mg)
  • Rosuvastatin (5-10 mg)
  • Simvastatin/ezetimibe (20/10 mg)
  • Simvastatin (20-40 mg)

Special Considerations for Rosuvastatin

• For patients with severe renal impairment (CrCl <30 ml/min) not on dialysis, the starting dose of rosuvastatin should be 5 mg once daily and should not exceed 10 mg once daily 2
• Asian patients may be at higher risk for myopathy with rosuvastatin and should be monitored carefully 2

Monitoring and Safety

• Statins appear to be generally safe in CKD patients at moderate doses (≤20 mg/day atorvastatin or simvastatin) 3
• Monitor for adverse effects including myopathy and rhabdomyolysis, which may be more common in CKD patients 2
• Temporary discontinuation of statins should be considered in patients experiencing acute illness with high risk of developing renal failure secondary to rhabdomyolysis 2
• Regular monitoring of liver enzymes is recommended, as increases in serum transaminases have been reported with statin use 2

Additional Benefits of Statins in CKD

• Statins may reduce proteinuria in patients with CKD 4, 5
• High-intensity statin therapy could effectively reduce the risk of stroke in CKD patients 6
• Statins reduce C-reactive protein as well as atherogenic lipid moieties such as ApoB, remnant particles, and oxidized LDL-C fraction 3

Common Pitfalls and Caveats

• Do not initiate statins in dialysis patients without atherosclerotic cardiovascular disease, as trials have shown no benefit 1
• The relationship between LDL-C and ASCVD events is weaker in CKD patients than in the general population, so treatment decisions should be based on absolute cardiovascular risk rather than LDL-C levels alone 1
• Consider dose adjustments for statins in patients with severe renal impairment to minimize adverse effects 2
• Be aware of potential drug interactions, especially with medications commonly used in CKD patients 2

In conclusion, statin therapy is recommended for most CKD patients not on dialysis, with the specific regimen determined by CKD stage, age, and cardiovascular risk factors. The evidence strongly supports their use for cardiovascular risk reduction in this high-risk population.