Update Lipid Management in Chronic Kidney Disease

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Update Lipid Management in Chronic Kidney Disease

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Outline

• The relationship between CVD CKD
• NKF-KDOQI guidelines
• ATP III guidelines
• Class effect of statin in CKD ?
• Safety Dose Modification

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Epidemiology of CKD in Taiwan
Lancet 2008
LIP-FM-1011020
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Relationship Between Estimated GFR (eGFR) and
Clinical Outcomes
Death from any cause Cardiovascular events Any
hospitalization Total events 51,424 Total
events 139,011 Total events 554,651
Age-standardized event rate (per 100 person-yr)
eGFR (mL/min/1.73 m2)
Kaiser Permanente Renal Registry, n1,120,295
adults aged ?20 years Median follow-up 2.84
years
Go AS et al. N Engl J Med. 20043511296-1305.
LIP-FM-1011020
LIP-FM-1011020
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Causes of death among period prevalent patients
19971999, treated with hemodialysis, peritoneal
dialysis, or kidney transplantation.
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Epidemiological Features of CKD in Taiwan
AJKD 20074946-55
LIP-FM-1011020
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LIP-FM-1011020
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LIP-FM-1011020
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LIP-FM-1011020
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KDOQI Clinical Practice Guidelines Managing
Dyslipidemias in Chronic Kidney Disease

• Guideline 11.1. All adults and adolescents with
  CKD should be evaluated for dyslipidemias. (B)
• 1.2. For adults and adolescents with CKD, the
  assessment of dyslipidemias should include a
  complete fasting lipid profile with total
  cholesterol, LDL, HDL, and triglycerides. (B)
• 1.3. For adults and adolescents with Stage 5 CKD,
  dyslipidemias should be evaluated upon
  presentation, at 23 months after a change in
  treatment or other conditions known to cause
  dyslipidemias and at least annually thereafter.
  (B)

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Total cholesterol LDL HDL TG/5
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the results of lipid-lowering trials are usually
generalizable to population subgroups.
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Treatment of Adults With Dyslipidemias

• 4.1. For adults with Stage 5 CKD and fasting
  triglycerides 500 mg/dL ( 5.65 mmol/L) that
  cannot be corrected by removing an underlying
  cause, treatment with therapeutic lifestyle
  changes (TLC) and a triglyceride-lowering agent
  should be considered. (C)
• 4.2. For adults with Stage 5 CKD and LDL 100
  mg/dL ( 2.59 mmol/L), treatment should be
  considered to reduce LDL to lt100 mg/dL (lt2.59
  mmol/L). (B)
• 4.3. For adults with Stage 5 CKD and LDL lt100
  mg/dL (lt2.59 mmol/L), fasting triglycerides 200
  mg/dL ( 2.26 mmol/L), and non-HDL cholesterol
  (total cholesterol minus HDL) 130 mg/dL ( 3.36
  mmol/L), treatment should be considered to reduce
  non-HDL cholesterol to lt130 mg/dL (lt3.36 mmol/L).
  (C)

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Summary
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ATP III guidelineLDL Cholesterol Goals and
Cutpoints for Therapeutic Lifestyle Changes
(TLC) Drug Therapy
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Class effect of statin in CKD ?
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CKD Subgroup
PLANET I Prospective evaLuation of proteinuriA
and reNal function in diabETic patients with
progressive renal disease
de Zeeuw D. 2010European Renal Association-Europea
n Dialysis and Transplant Association Congress
June 27, 2010 Munich, Germany.
LIP-FM-1011020
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For PLANET I (diabetic patients), de Zeeuw
summarized

• "Atorvastatin significantly reduces the
  proteinuria in these patients on top of ACE/ARB
  therapy, with around a 15 reduction in
  proteinuria, whereas rosuvastatin, both 10 and
  40 mg, had no significant effect at all on
  proteinuria."

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JACC 2008 51(25) 2375-84
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Case 1

• 82 year-old man
• CAD/TVD, HTN, HL, CKD (stage 4)
• Presented with cyanosis of both feet toes in
  progression and gangrene change of right toes now
• CTA showed severe and diffuse calcified both CFA
  and SFA , suspect CTO at right SFA proximal part.

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Final angiography
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Case 2

• 66 year-old
• Heavy smoker
• HTN with adalat OROS 2 bid, lasix 1qd, doxaben
  1qd, imdur 1qd, concor 1qd ? BP 170/100 mmHg
• CKD (Cr 3.5mg/dl, stage 4)
• HL
• Vertebrobasilar insufficiency
• CAD/TVD post PCI
• Bilateral ICA stenosis post CAS
• Renal echo right 7.5cm, left 9.2cm, no
  hydronephrosis

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Case 3

• 82 year-old man
• CC right hemaparesis and slurred speech in the
  recent 6 months
• Risk factors HTN, hyperlipidemia
• Repeated transient slurred speech and right
  hemiparesis recently obvious claudication of
  both lower extremities post 2-minute walking.
• Cre 1.4 mg/dl (CKD stage 3)
• cholesterol 185 mg/dl
• TG 179 mg/dl
• LDL 98 mg/dl
• HDL 45 mg/dl

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Case 4

• 72 year-old man
• HL, DM, CKD (stage 3)
• Unstable angina

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