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Guidelines set approach for adults with chronic kidney disease

Published: 7:00 am CDT, December 27, 2013

Recent guidelines for managing cholesterol  in people with chronic kidney disease recommend that doctors decide which drugs to prescribe on the basis of patients’ overall risk of coronary events, not just on their low-density lipoprotein or “bad” cholesterol levels.

Kidney Disease Improving Global Outcomes released the guidelines in November and say the use of cholesterol-lowering drugs like statins should be based on scientific evidence showing their potential to  produce a beneficial outcome, like reducing the occurrence of future coronary events.

The non-profit foundation defined chronic kidney disease as abnormalities of kidney structure or function that are present for more than three months.

Marcello Tonelli, M.D. and Christoph Wanner, M.D., the co-chairs of the kidney foundation’s lipid guideline development work group, wrote a summary of recommendations in the Annals of Internal Medicine.

The group’s recommendation, which would expand the use of statin therapy, is similar to recommendations made in prevention guidelines by the American Heart Association and American College of Cardiology, released earlier in November.

“Previous studies convincingly demonstrated that the prevalence of statin use among persons with CKD who were at risk for cardiovascular events was lower than among otherwise similar persons with normal kidney function,” Tonelli and Wanner wrote in the summary. “We are optimistic that the current guideline will help to close this quality gap by emphasizing the high cardiovascular risk associated with CKD (regardless of LDL cholesterol levels) while also reducing complexity for practitioners and enhancing implementation.”

Statins are drugs that prevent the formation of cholesterol in the liver. They’re most effective at lowering the LDL cholesterol, but also have modest effects on lowering triglycerides (blood fats) and raising HDL (good) cholesterol.

“In the past, statin use in people with CKD was limited because early clinical statin trials excluded people with moderate to severe CKD,” said Sylvia Rosas, M.D., a nephrologist and epidemiologist at the Joslin Diabetes Center and Beth Israel Deaconess Hospital in Boston, Mass., and an American Heart Association spokesperson. ”However, recent clinical trials of patients with CKD not on dialysis have found the use of statins to be beneficial.”

Tonelli and Wanner wrote that because people with chronic kidney disease already have a higher risk of coronary events and death, LDL alone can’t guide decisions on cholesterol-lowering treatment.

“Although higher levels of LDL cholesterol are associated with higher risk, dialysis patients with the lowest levels of LDL cholesterol and total cholesterol are also at very high risk for all-cause and cardiovascular mortality, likely because of confounding by inflammation and malnutrition,” they wrote.

Although evidence did not specify a risk level for initiating cholesterol treatment, Tonelli and Wanner said that risk of coronary death or a nonfatal heart attack of more than 10 percent over 10 years was “a reasonable working definition.”

They added that people 50 and older with chronic kidney disease consistently exceed this 10 percent over 10 year risk level.

The recommendations said that the strongest medical evidence supported the use of statins with or without ezetimibe (Zetia), another cholesterol-lowering drug that prevents cholesterol from being absorbed from the intestine.

The guidelines are based upon a systematic review of medical research published through August 2011, with an additional review of evidence published through June 2013.

Like the AHA and ACC prevention guidelines, the kidney disease guideline authors say the goal is to inform healthcare providers and  help them make decisions about care, but not to dictate an mandatory standard of care. They add that treatment decisions should also include input from patients themselves, and in some cases may be limited by the availability of resources.

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