LDL-c levels no longer central to guiding treatment in patients with chronic kidney disease
Specific LDL-c treatment targets are no longer recommended in guidelines on managing lipids in patients with chronic kidney disease (CKD), as released by Kidney Disease: Improving Global Outcome (KDIGO). It is now recommended that the decision to initiate cholesterol-lowering treatment - specifically statin therapy - should be based on the absolute risk of coronary events, and evidence that a therapy will help lower that risk.
CKD is associated with high cardiovascular (CV)s risk, irrespective of LDL-c levels. However, persons with CKD are less often on statins than other people with similar CV risk but with normal renal function.
Dialysis patients with the lowest levels of LDL-c and total cholesterol are also at substantial risk for all-cause and cardiovascular mortality. Although higher LDL-c levels are associated with a higher risk, in the case of non-dialysis-dependent CKD, the magnitude of the excess risk associated with increased LDL-c levels decreases at lower estimated glomerular filtration rates. Thus, a weaker and potentially misleading association exists between LDL-c and coronary risk in patients with poor renal function who have the highest absolute coronary risk. This argues against a role for LDL-c in identifying CKD-patients who should be on cholesterol-lowering medication.
Although no optimal threshold to initiate cholesterol-lowering treatment is given, a 10-year risk for coronary death or nonfatal myocardial infarction that exceeds 10% could be a good guidance.
The advice of KDIGO's lipid guideline development work group follows the recommendations of the much debated new AHA/ACC prevention guidelines. The KDIGO Clinical Practice Guideline offers practical recommendations on the assessment of lipid status and the use of lipid-lowering drugs, based on the most recent randomised trials involving CKD patients. Among other things, it is recommended to give statin or statin with ezetimibe to 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.
A synopsis of the Kidney Disease: Improving Global Outcomes 2013 Clinical Practice Guideline is available online