In a chronic kidney disease stage 3‑4 patient with normal sodium and potassium, fasting blood glucose 5.3 mmol/L, LDL cholesterol 3.6 mmol/L, and currently taking losartan, amlodipine, and sodium bicarbonate, what medication adjustment should be made?

Statin Therapy Initiation for Lipid Management in CKD Stage 3–4

Add atorvastatin 20 mg daily to the current regimen, as this patient meets criteria for statin therapy based on age ≥50 years and eGFR <60 mL/min/1.73 m² (implied by CKD stage 3–4), regardless of the current LDL-C level of 3.6 mmol/L (139 mg/dL). 1

Rationale for Statin Initiation

• The 2024 KDIGO guideline strongly recommends initiating statin or statin/ezetimibe combination therapy in all adults ≥50 years with CKD stage 3–5 (eGFR <60 mL/min/1.73 m²), irrespective of baseline LDL cholesterol levels. 1, 2 The decision is driven by absolute cardiovascular risk (age + reduced eGFR), not by lipid targets. 1, 2

• The 10-year risk of coronary death or myocardial infarction consistently exceeds 10% in this population, eliminating the need to check lipid levels before starting therapy. 2

• Statins reduce major atherosclerotic events by approximately 17% in non-dialysis CKD patients. 2

Why Atorvastatin Is the Preferred Agent

• Atorvastatin requires no dose adjustment regardless of renal function severity, including stage 4 CKD (eGFR 15–29 mL/min/1.73 m²). 2 This makes it operationally simpler and safer than alternatives. 2

• Atorvastatin has the lowest renal excretion (<2%) among statins, making it favorable for patients with renal impairment. 2

• In contrast, rosuvastatin requires dose restriction (maximum 10 mg daily) when CrCl <30 mL/min/1.73 m². 2, 3 Simvastatin and lovastatin also require dose adjustments in severe kidney disease. 2

Recommended Starting Dose

• Initiate atorvastatin 20 mg daily for primary or secondary prevention in patients ≥50 years with eGFR <60 mL/min/1.73 m². 2 This dose is appropriate for CKD stage 3–4 without requiring adjustment. 2

• For patients with established coronary disease or diabetes with CKD, consider atorvastatin 40–80 mg daily targeting LDL-C <70 mg/dL (1.8 mmol/L), although the exact dosage should be individualized based on cardiovascular risk. 1, 2

LDL-C Target Considerations

• The primary LDL-C goal is <100 mg/dL (2.6 mmol/L) for all CKD stage 3–4 patients. 2 This patient's current LDL-C of 3.6 mmol/L (139 mg/dL) exceeds this target. 2

• An optional intensive target of <70 mg/dL (1.8 mmol/L) provides additional cardiovascular benefit in patients with diabetes and CKD stages 1–4. 1, 2 The 2022 Mayo Clinic guideline and European Society of Cardiology recommend LDL-C <1.8 mmol/L for very high-risk patients (CKD stage 3–5 or CKD with diabetes/CVD). 1, 2

• However, LDL-C levels should not guide treatment decisions in CKD; treatment is based on absolute cardiovascular risk (age + eGFR) rather than lipid levels. 1, 2

Monitoring Strategy

• Reassess lipid panel 2–3 months after initiation or dose adjustment. 1

• Routine repeat lipid testing after statin initiation is not required, except when assessing adherence or investigating new secondary causes of dyslipidemia. 2

• If LDL-C target is not achieved with maximum tolerated statin dose, adding ezetimibe 10 mg daily is recommended. 1, 2

Safety Considerations

• Monitor for statin-related myopathy, especially in patients ≥65 years, with hypothyroidism, or taking interacting medications. 2

• Avoid concomitant use of strong CYP3A4 inhibitors (e.g., cyclosporine, gemfibrozil) with atorvastatin to reduce myopathy risk. 1, 2

• Atorvastatin can be continued if the patient progresses to dialysis, but new statin therapy should not be initiated once dialysis-dependent. 1, 2

Current Medication Review

• Continue losartan 50 mg daily for renoprotection and blood pressure control. Losartan provides effective renoprotection in normotensive patients with nondiabetic stage 3 CKD without changing blood pressure. 4

• Continue amlodipine for blood pressure management, as calcium channel blockers are appropriate in CKD. 1

• Continue sodium bicarbonate for metabolic acidosis management, ensuring serum bicarbonate does not exceed the upper limit of normal and does not adversely affect blood pressure control, serum potassium, or fluid status. 1

Common Pitfalls to Avoid

• Do not withhold statin therapy based on "normal" LDL-C levels. The most frequent error is using LDL-C levels to determine the need for statin therapy in CKD patients; treatment should be based on absolute cardiovascular risk (age + eGFR). 2

• Do not reduce atorvastatin dose based solely on CKD stage 3–4 status—no adjustment is needed or recommended. 2

• Do not use rosuvastatin as first-line in this patient without considering dose restrictions required for severe renal impairment. 2, 3