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.

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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)

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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

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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.

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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