November 13, 2014

Guidelines agree: Most patients with chronic kidney disease should take statins

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UAB researchers compared two sets of guidelines to ascertain if people with chronic kidney disease should take statins to reduce high cholesterol levels linked to cardiovascular disease.

cholesterolA gradual loss of kidney function over time — or chronic kidney disease (CKD) — increases the risk of heart disease and stroke. Two sets of cholesterol-treatment guidelines published in 2013 inform the decision to use statins.

One set is specifically for patients with CKD, while the other is for the general population. University of Alabama at Birmingham experts compared them to find similarities and differences and to also determine if CKD patients are taking statins unnecessarily.

Around 26 million adults in the United States have CKD, according to the National Kidney Foundation, and heart disease and stroke are major causes of death among them.

In “Contrasting Cholesterol Management Guidelines for Adults with CKD,” published in the Journal of the American Society of Nephrology, UAB School of Public Health investigators compared the American College of Cardiology/American Heart Association cholesterol treatment guideline and the Kidney Disease Improving Global Outcomes Foundation Clinical Practice Guideline for Lipid Management in CKD.

Study lead author Lisandro Colantonio, M.D., doctoral candidate in the UAB Department of Epidemiology, said the two guidelines target different populations in treatment recommendations.

“The ACC/AHA guideline is aimed toward statin treatment decisions for the general population, while the KDIGO guideline is intended to guide treatment of patients with kidney disease,” Colantonio said.

The ACC/AHA guideline recommends statin treatment to individuals with a high risk of cardiovascular disease (CVD; heart disease or stroke) based on a history of CVD, diabetes or an estimated 10-year risk ≥7.5 percent using the Pooled Cohorts risk equations. The KDIGO guideline recommends statin therapy for all people ages 50-79 with CKD.

“While most patients with CKD are at high risk for CVD, we hypothesized that some patients with CKD are not at high risk and therefore may be unnecessarily recommended statins by the KDIGO guideline. Therefore, we felt it was important to understand in what ways the two cholesterol-treatment recommendations are similar and how they may be different.”

“While most patients with CKD are at high risk for CVD, we hypothesized that some patients with CKD are not at high risk and therefore may be unnecessarily recommended statins by the KDIGO guideline,” Colantonio said. “Therefore, we felt it was important to understand in what ways the two cholesterol-treatment recommendations are similar and how they may be different.”

Using data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a cohort of more than 30,000 U.S. adults, the researchers found that 92 percent of people with CKD are recommended statin treatment by the 2013 general population ACC/AHA cholesterol treatment guideline versus 100 percent following the KDIGO guideline for patients with CKD.

“These results indicate that either guideline can be used to inform the decision to initiate statin therapy for people with CKD who are 50 to 79 years of age,” Colantonio said.

Study senior author Paul Muntner, Ph.D., professor in the UAB Department of Epidemiology, notes that while both the ACC/AHA and KDIGO guidelines recommend statins as the first therapy to prevent CVD among those with high risk, this treatment is not for all CKD patients.

“In contrast, prior studies on individuals with CKD who are on dialysis have shown no benefit of statins to prevent CVD,” Muntner said. “Both guidelines agree that statin therapy should not be initiated in those individuals on dialysis.”

Also discovered was that 50 percent of people with CKD who are recommended statins are not taking them.

“This represents an unmet treatment need, and there is a missed opportunity for lowering CVD risk among patients with CKD,” Colantonio said.

Colantonio adds that they did find that the Pooled Cohort risk equations were accurate among people with CKD, indicating that physicians have a valid tool available to accurately estimate CVD risk for their patients with CKD.

Both authors say an unanswered question is whether it is appropriate to initiate statins for people ages 80 and older; the KDIGO guideline recommends statins but the ACC/AHA guideline does not.

This study was supported by the National Institute of Neurological Disorders and Stroke of the National Institutes of Health.

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