From the Guidelines
Management of hypercholesterolemia in chronic kidney disease (CKD) should focus on statins as first-line therapy, with dosing adjusted for kidney function, as recommended by the Kidney Disease: Improving Global Outcomes (KDIGO) organization 1.
Key Recommendations
- For non-dialysis CKD patients, moderate to high-intensity statins like atorvastatin 20-40 mg daily or rosuvastatin 10-20 mg daily are recommended, with rosuvastatin requiring dose reduction in advanced CKD.
- For patients on dialysis, statin initiation is generally not recommended unless they already have atherosclerotic cardiovascular disease or are kidney transplant recipients.
- Ezetimibe 10 mg daily can be added for patients not reaching target LDL levels on maximum tolerated statin doses.
- PCSK9 inhibitors like evolocumab or alirocumab may be considered for high-risk patients with persistently elevated LDL despite optimized statin and ezetimibe therapy.
Rationale
The KDIGO guideline development work group formulated the scope of the guideline and graded evidence on the basis of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system 1. The work group recommended statin or statin with ezetimibe treatment of adults aged 50 years or older with estimated glomerular filtration rates less than 60 mL/min/1.73 m2 but not treated with long-term dialysis or kidney transplantation. The guideline also emphasizes the importance of considering the patient's CKD stage, cardiovascular risk, and life expectancy when making treatment decisions.
Monitoring and Follow-up
Regular monitoring of lipid levels every 3-6 months and liver function tests is essential to ensure the safety and efficacy of lipid-lowering therapy in CKD patients. The KDIGO guideline recommends that the lipid profile should ideally be measured in the fasting state, but nonfasting values provide useful information as well 1.
From the Research
Hypercholesterolemia in CKD
- Hypercholesterolemia is a common condition in patients with chronic kidney disease (CKD) and increases the risk of cardiovascular disease (CVD) events 2.
- Statins are the first-line lipid-lowering therapy in patients with CVD and CKD, with some statins requiring dose adjustments based on renal function 2.
- Ezetimibe can be prescribed in patients with CVD and CKD, usually combined with a statin, to help achieve recommended low-density lipoprotein cholesterol (LDL-C) levels 2, 3.
Treatment Options
- The rosuvastatin/ezetimibe combination is safe and effective in patients with hypercholesterolemia or dyslipidemia, with or without diabetes and with or without CVD 3, 4.
- Fenofibrate and omega 3 fatty acids can lower triglyceride levels, but their cardiorenal benefits in patients with CVD and CKD remain to be established 2.
- Proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors, cholesterol-reducing nutraceuticals, bempedoic acid, and apabetalone may be potential treatment options, but further research is needed 2.
Cardiovascular Risk Stratification
- Different strategies have been proposed to stratify cardiovascular risk and assess the appropriate use of statins in patients with CKD 5.
- According to the 2019 ESC/EAS and 2013 KDIGO guidelines, a large proportion of patients with CKD are eligible for statin therapy, but observed statin use is often deficient and current lipid goals are not achieved in most cases 5.
- Choosing the right statin for individual patients, considering efficacy and safety in specific clinical situations, such as CKD, is crucial to minimize side effects and improve compliance 6.