Clinical Guidelines on Dyslipidemia Management in CKD
Several professional medical societies have established recommendations for dyslipidemia management for patients with CKD. The National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines are applicable to the general population of primary care patients, including those with CKD.22 Although published more than a decade ago, the ATP III guidelines (and the 2004 focused update)23 remain the standard of care for dyslipidemia management in the primary care setting. A revised NCEP guideline, ATP IV, is in development and will be released later this year or early next year.
The 2003 KDOQI guidelines provide specific guidance on the treatment of dyslipidemia in the presence of CKD.24 The KDOQI recommendations include specific treatment targets for each lipid parameter as well as recommendations for initial, add-on, and alternative therapies (Table 3).
The key differences between the KDOQI and ATP III recommendations are summarized in Table 4. Importantly, the NKF recommends that all stages of CKD should be considered a CHD risk equivalent. Accordingly, all patients with CKD belong to the highest risk group for CHD, and KDOQI advises that low-density lipoprotein cholesterol (LDL-C) should be lowered to <100 mg/dL (<2.6 mmol/L).
In 2008, the Canadian Society of Nephrology (CSN) and the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom published guidelines for the management of CKD.25,26 These guidelines add to the growing consensus supporting the use of statin therapy to reduce the risk of cardiovascular morbidity and mortality in patients with CKD.
The CSN guidelines26 are largely consistent with the recommendations of the NKF and ATP III:
- For patients with stages 1 to 3 CKD, statin therapy should be initiated and titrated according to existing lipid guidelines for the general population.
- Patients with stage 4 CKD should be treated with statin therapy dosed to achieve an LDL-C level <2.0 mmol/L (<177.2 mg/dL) and a total cholesterol-to-HDL-C ratio <4.0.
- Treatment with gemfibrozil (1200 mg/d) is an alternative to statin therapy for patients with CKD stages 1 to 3 who are at intermediate or high cardiovascular risk with concomitant low HDL-C levels (<1.0 mmol/L, ~40 mg/dL).
- At any stage of CKD, fasting TG >10 mmol/L (>180 mg/dL) should be managed with lifestyle changes and treatment with gemfibrozil or niacin to reduce the risk of pancreatitis.
The 2008 NICE guidelines recommend statin therapy for primary prevention of CVD in patients with CKD according to lipid guidelines for the general population.25 NICE recommends statins for the secondary prevention of cardiovascular events for all patients with CKD regardless of baseline lipid values. The NICE guidelines do not include recommendations for secondary lipid-modifying therapy for patients with CKD.
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