Full lipid profiles are recommended for all patients with chronic kidney disease (CKD) at first presentation, according to a new guideline developed by a work group of the Kidney Disease: Improving Global Outcomes (KDIGO) organization.
“No direct evidence indicates that measuring lipid status will lead to better clinical outcomes,” the guideline states. “However, measuring lipid status is noninvasive, inexpensive, and might improve the health of people with secondary dyslipidemia.” In the judgment of the work group, “these considerations justify a strong recommendation despite the low quality of the supporting evidence.”
In addition, the guideline recommends that patients aged 50 years and older with an estimated glomerular filtration rate (eGFR) below 60 mL/min/1.73 m2—but not treated with chronic dialysis or kidney transplantation—be treated with a statin alone or in combination with ezetimibe. The guideline recommends statin treatment for patients aged 50 years and older with CKD and an eGFR of 60 or higher.
For adults aged 18-49 years with CKD not treated with dialysis or kidney transplantation, the guideline recommends statin treatment if one or more of the following are present: known coronary disease, diabetes mellitus, prior ischemic stroke, or a greater than 10% estimated 10-year incidence of coronary death or non-fatal myocardial infarction.
The work group, led by Christoph Wanner, MD, of University Hospital Wurzburg in Wurzburg, Germany, suggests that statins alone or in combination with ezetimibe not be initiated in adult dialysis patients. They pointed out that three large trials have failed to show a conclusive benefit of statin treatment among prevalent dialysis patients, “raising the hypothesis that inadequate statistical power was responsible for the apparent lack of benefit. Nonetheless, it is clear that even if statins do prevent cardiovascular events in prevalence dialysis patients, the magnitude of any relative reduction in risk is substantially smaller than in early stages of CKD.”
The guideline, which was published online ahead of print in Kidney International, suggests that patients already receiving statins or a statin/ezetimibe combination at the time of dialysis initiation should continue to receive these agents.
In adults with CKD, including those treated with chronic dialysis or kidney transplantation, follow-up measurement of lipid levels is not required for most patients.
According to the work group, follow-up measurement of lipid levels should be reserved for instances in which the results would alter management. Possible reasons for follow-up lipid measurements include assessment of adherence to statin treatment, a change in renal replacement therapy modality, concern about the presence of a new secondary cause of dyslipidemia, or to assess the 10-year cardiovascular risk in patients younger than 50 years and not currently receiving a statin.