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STATE-OF-THE-ART PAPER

Managing Dyslipidemia in Chronic Kidney Disease

Charles R. Harper, MD, FACP^_* and Terry A. Jacobson, MD, FACP^_*,,_*

^_* Department of Medicine, Emory University, Atlanta, Georgia
Office of Health Promotion and Disease Prevention, Emory University, Atlanta, Georgia.

Manuscript received November 20, 2007; revised manuscript received February 12, 2008, accepted March 4, 2008.

^_* Reprint requests and correspondence: Dr. Terry A. Jacobson, Department of Medicine, Emory University, 49 Jesse Hill Junior Drive, Atlanta, Georgia 30303. (Email: tjaco02{at}emory.edu).

The incidence of chronic kidney disease (CKD) in the U.S. continues to increase, and now over 10% of the U.S. population has some form of CKD. Although some patients with CKD will ultimately develop renal failure, most patients with CKD will die of cardiovascular disease before dialysis becomes necessary. Patients with CKD have major proatherogenic lipid abnormalities that are treatable with readily available therapies. The severe derangements seen in lipoprotein metabolism in patients with CKD typically results in high triglycerides and low high-density lipoprotein (HDL) cholesterol. Because of the prevalence of triglyceride disorders in patients with CKD, after treating patients to a low-density lipoprotein goal, non-HDL should be calculated and used as the secondary goal of treatment. A review of the evidence from subgroup analysis of several landmark lipid-lowering trials supports treating dyslipidemia in mild to moderate CKD patients with HMG-CoA reductase inhibitors. The evidence to support treating dyslipidemia in hemodialysis patients, however, has been mixed, with several outcome trials pending. Patients with CKD frequently have mixed dyslipidemia and often require treatment with multiple lipid-lowering drugs. Although statins are the cornerstone of therapy for most patients with CKD, differences in their pharmacokinetic properties give some statins a safety advantage in patients with advanced CKD. Although most other lipid-lowering agents can be used safely with statins in combination therapy in patients with CKD, the fibrates are renally metabolized and require both adjustments in dose and very careful monitoring due to the increased risk of rhabdomyolysis. After reviewing the safety and dose alterations required in managing dyslipidemia in patients with CKD, a practical treatment algorithm is proposed.

Abbreviations and Acronyms   CHD = coronary heart disease   CKD = chronic kidney disease   CVD = cardiovascular disease   CYP-3A4 = cytochrome p450-3A4   GFR = glomerular filtration rate   HDL-C = high-density lipoprotein cholesterol   LDL-C = low-density lipoprotein cholesterol   MI = myocardial infarction   NKF = National Kidney Foundation   NLA = National Lipid Association