In 2003, the National Kidney Foundation published the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines, which included recommendations for assessment and treatment of dyslipidemia in patients with chronic kidney disease (CKD). The KDOQI guidelines recommend evaluation of all patients with CKD for dyslipidemia through testing for:
For patients with stage 5 CKD, the lipid panel should be performed at presentation, annually thereafter, and at 2 to 3 months after every change in treatment. In addition, patients with dyslipidemia should be evaluated for possible secondary causes of dyslipidemia:
Pankaj Shah, M.D., of the Division of Endocrinology, Diabetes, Metabolism, and Nutrition at Mayo Clinic says: "Cardiovascular events are the No. 1 cause of death in patients with CKD. These patients have an increase in their blood concentrations of LDL-C, non–HDL-C, small dense LDL-C, modified LDL-C, lipoprotein(a), and C-reactive protein.
"The increase in blood triglycerides and decrease in HDL-C are more marked in CKD patients who also have nephrotic syndrome. The KDOQI guidelines recommend treatment with a fibrate or niacin when the blood triglycerides concentration is 500 mg/dL or greater and the patient has no response to therapeutic lifestyle interventions. The targets and treatment strategies for blood LDL-C concentrations are not different from people without CKD.
"Patients with severe CKD were not included in the large randomized placebo-controlled trials that were designed to assess the effects of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins)."
Dr. Shah notes: "However, secondary analyses of the data from patients with mild to moderate CKD showed that treatment with statins caused statistically significant reductions in all-cause and cardiovascular mortality rates. These benefits seemed to be at least as remarkable as those found in the people without CKD.
"In addition, statins have been shown to be safe for patients with CKD, and they do not impact renal function. Yet, 2 large trials conducted of patients receiving hemodialysis revealed a lack of benefit from statin use in decreasing cardiovascular events or death, despite declines in blood lipid concentrations similar to those seen in patients with mild to moderate CKD. In addition, gemfibrozil use for patients with mild to moderate CKD has not been shown to have an impact on major cardiovascular events or overall mortality rate."
Dr. Shah continues: "There is only 1 large study addressing the cardiovascular and survival benefits of statins in renal transplant recipients. A clinically significant reduction in hyperlipidemia, similar to that seen in patients with mild to moderate CKD, was observed in this study. Although there was a trend for reduced cardiovascular events, there was no impact on mortality outcomes. Potential effects of statin treatment on prevention of organ rejection, though, are under investigation.
"Screening for and treatment of dyslipidemia in patients with mild to moderate kidney disease appear to have fair evidence. However, statin use for patients receiving hemodialysis and for renal transplant recipients does not have a strong evidence base. More studies are required to establish the role of statins in patients with stage 5 CKD and renal transplant recipients."