Rosuvastatin Dosing in Chronic Kidney Disease
For patients with CKD and creatinine clearance <30 mL/min/1.73 m² not on hemodialysis, initiate rosuvastatin at 5 mg once daily and do not exceed 10 mg once daily. 1
Dosing Algorithm by Renal Function
Mild to Moderate CKD (eGFR ≥30 mL/min/1.73 m²)
- No dose adjustment required for rosuvastatin in patients with mild to moderate renal impairment 2, 1
- Standard dosing range of 5-40 mg daily can be used based on cardiovascular risk and lipid goals 1
Severe CKD (CrCl <30 mL/min/1.73 m², not on dialysis)
- Start at 5 mg once daily 2, 3, 1
- Maximum dose: 10 mg once daily 2, 3, 1
- This restriction is due to reduced renal excretion and increased plasma concentrations in severe renal impairment 3, 4
Dialysis Patients
- Do not initiate rosuvastatin in patients already on hemodialysis or peritoneal dialysis 3, 4
- If already taking rosuvastatin when dialysis is initiated, continuation may be considered with the same dose restrictions (5 mg starting dose, maximum 10 mg daily) 3, 4
- This recommendation stems from the AURORA trial, which showed no cardiovascular benefit with rosuvastatin 10 mg daily in hemodialysis patients 4
Comparison with Atorvastatin
Atorvastatin is actually the preferred statin for advanced CKD because it requires no dose adjustment regardless of kidney function severity 3, 5. Key advantages include:
- Atorvastatin can be dosed 10-80 mg daily without modification in any degree of renal impairment, including stage 4-5 CKD 3, 5
- Minimal renal excretion (<2%) makes it operationally simpler and safer 3, 5
- No maximum dose cap in severe renal impairment, allowing for high-intensity therapy when needed 3, 5
In contrast, rosuvastatin's dose restriction to maximum 10 mg daily in severe CKD limits its utility for intensive lipid lowering 3, 4
Clinical Efficacy Evidence in CKD
Despite dose restrictions, rosuvastatin demonstrates benefits in non-dialysis CKD patients:
- Reduces cardiovascular events by 45% in patients with moderate CKD (eGFR <60 mL/min/1.73 m²) and elevated hsCRP 6
- Reduces all-cause mortality by 44% in this population 6
- May stabilize or marginally improve eGFR and reduce albuminuria 7, 8, 9
- Effectively reduces LDL-C, triglycerides, and inflammatory markers even at lower doses (2.5-10 mg) 7, 9
Critical Implementation Points
Monitor for myopathy risk, which is increased in CKD patients due to higher drug exposure 3, 1
Avoid concomitant gemfibrozil or use with extreme caution (maximum 10 mg rosuvastatin daily if combination necessary) 1
Consider drug interactions that further restrict dosing: cyclosporine limits rosuvastatin to 5 mg daily maximum, while multiple antivirals and other medications require dose caps 1
Asian patients require additional caution, starting at 5 mg daily due to increased plasma concentrations regardless of renal function 1
Practical Recommendation
For most CKD patients requiring statin therapy, consider atorvastatin 20-40 mg daily as first-line due to its lack of renal dose restrictions and operational simplicity 3, 5. Reserve rosuvastatin for specific situations where it offers advantages (such as patients already stable on it), but strictly adhere to the 5 mg starting dose and 10 mg maximum in severe CKD 2, 3, 1.