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Update Lipid Management in Chronic Kidney Disease
成大醫院心臟內科李政翰醫師助理教授
Outline
• The relationship between CVD & CKD
• NKF-KDOQI guidelines
• ATP III guidelines
• Class effect of statin in CKD ?
• Safety & Dose Modification
LIP-FM-1011020
Epidemiology of CKD in TaiwanLancet 2008
LIP-FM-1011020
Relationship Between Estimated GFR (eGFR) and Clinical Outcomes
Go AS et al. N Engl J Med. 2004;351:1296-1305.
Ag
e-st
and
ard
ized
eve
nt
rate
(p
er 1
00 p
erso
n-y
r)
Death from any cause Cardiovascular events Any hospitalizationTotal events = 51,424 Total events = 139,011 Total events = 554,651
Kaiser Permanente Renal Registry, n=1,120,295 adults aged 20 years Median follow-up = 2.84 years
eGFR (mL/min/1.73 m2)
LIP-FM-1011020
Causes of death among period prevalent patients 1997–1999, treated
with hemodialysis, peritoneal dialysis, or kidney transplantation.
Epidemiological Features of CKD in Taiwan
AJKD 2007;49:46-55
--1.000 No atherosclerotic vascular
<0.0013.134-3.3723.251 Atherosclerotic vascular disease†
--1.000 No hyperlipidemia
<0.0013.341-3.6053.471 Hyperlipidemia
--1.000 No hypertension
<0.0013.757-4.0313.892 Hypertension
--1.000 No diabetes
<0.0014.528-4.8944.707 Diabetes
Comorbidity
P95% CICrude OR
Crude ORs for the Development of CKD, From 1997 to 2003 Crude ORs for the Development of CKD, From 1997 to 2003
LIP-FM-1011020
LIP-FM-1011020
LIP-FM-1011020
LIP-FM-1011020
KDOQI Clinical Practice Guidelines
Managing Dyslipidemias in Chronic Kidney Disease • Guideline 1
1.1. 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 2–3 months after a change in treatment or other conditions known to cause dyslipidemias; and at least annually thereafter. (B)
Total cholesterol = LDL +HDL +TG/5
the results of lipid-lowering trials are usually generalizable to population subgroups.
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 <100 mg/dL (<2.59 mmol/L). (B)
• • 4.3. For adults with Stage 5 CKD and LDL <100 mg/dL (<2.59 m
mol/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 <130 mg/dL (<3.36 mmol/L). (C)
Summary
ATP III guidelineLDL Cholesterol Goals and Cutpoints for
Therapeutic Lifestyle Changes (TLC) & Drug Therapy
Risk CategoryLDL Goal(mg/dL)
LDL Level at Which to Initiate Therapeutic Lifestyle Changes
(TLC) (mg/dL)
LDL Level at Which to Consider
Drug Therapy (mg/dL)
CHD or CHD Risk Equivalents
(10-year risk >20%)<100 100
130 (100–129: drug
optional)
2+ Risk Factors (10-year risk 20%)
<130 130
10-year risk 10–20%: 130
10-year risk <10%: 160
0–1 Risk Factor <160 160
190 (160–189: LDL-lowering drug
optional)
Class effect of statin in CKD ?
PLANET I : Prospective evaLuation of proteinuriA and reNal function in diabETic patients with progressive renal
disease
de Zeeuw D. 2010European Renal Association-European Dialysis and Transplant Association Congress;
June 27, 2010; Munich, Germany.
LIP-FM-1011020
CKD Subgroup
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."
JACC 2008 51(25) 2375-84
• 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.
Case 1
Final angiography
Case 2• 66 year-old• Heavy smoker• HTN with adalat OROS 2# bid, lasix 1#qd, doxaben 1
#qd, imdur 1#qd, concor 1#qd 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 hydroneph
rosis
Case 3• 82 year-old man• CC: right hemaparesis and slurred speech in the rec
ent 6 months• Risk factors: HTN, hyperlipidemia• Repeated transient slurred speech and right hemipar
esis 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
Case 4
• 72 year-old man
• HL, DM, CKD (stage 3)
• Unstable angina
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