Statins Vastly Underprescibed for Chronic Kidney Disease Patients

The vast majority of patients with chronic kidney disease (CKD) are recommended to receive statins under current cholesterol management guidelines, but half of those patients are not taking the drugs, according to a study that will appear in an upcoming issue of the Journal of the American Society of Nephrology.¹

Dyslipidemia guidelines published by the Kidney Disease Improving Global Outcomes Lipid Work Group (KDIGO) recommend that all CKD patients aged 50 to 79 years receive statins, but the guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) are slightly more complicated. The ACC/AHA guidelines recommend use of statins in patients with atherosclerotic cardiovascular disease (ASCVD), those with low-density lipoprotein (LDL) cholesterol levels of 190 mg/dL or higher, certain patients with diabetes, and a subset of patients with a 10-year predicted risk for ASCVD of 7.5% or higher.²

From a 30,000-patient database, Lisandro Colantonio, MD, MSc, and colleagues identified those with CKD and then estimated the percentage of patients who would be candidates for statin therapy under current guidance. The investigators defined CKD as an estimated glomerular filtration rate of 60 ml/min or less per 1.73 m² of body surface area, or as urine albumin levels of 30 mg per gram or greater. Importantly, patients with CKD in the study were limited to those not undergoing dialysis.^1,2

After analyzing the patients’ records, the researchers concluded that the vast majority (92%) were candidates for statin therapy under the ACC/AHA guidance, whereas all of them were candidates under KDIGO guidelines.¹

Based on those findings, the authors determined that approximately half of the more 20 million adults in the United States with CKD are good candidates for statin therapy but are not receiving it. In a press release, Dr. Colantonio noted, “There is an unmet treatment need and a missed opportunity for lowering heart disease risk among patients with CKD.”¹

Previous studies, such as the SHARP study, identified a 22% lower risk of cardiovascular events in patients with CKD undergoing hemodialysis and taking simvastatin 20 mg daily with ezetimibe 10 mg daily. However, other studies, such as AURORA, found no significant cardiovascular benefit with rosuvastatin, and in the SHARP study, the use of statins came at the cost of a significantly increased risk of muscle symptoms requiring treatment discontinuation (1.1% for patients taking active treatment vs 0.6% in patients receiving placebo, P = .02).^3,4

Although it is important to recognize that guidelines recommend the use of statins for virtually all patients with CKD who are not undergoing dialysis, it is also vital to treat patients as individuals and not overgeneralize guideline recommendations. Nevertheless, it is important for all CKD patients to discuss the relative risks and benefits of statin therapy with a qualified health care professional to help reduce the gap in care between guideline recommendations and current treatment patterns.

References:

1. EurekAlert. Guidelines say nearly all patients with chronic kidney disease should take statins. http://www.eurekalert.org/pub_releases/2014-11/ason-gsn110714.php. Accessed November 2014.

2. Colantonio LD, Baber U, Banach M, et al. Contrasting Cholesterol Management Guidelines for Adults with CKD. J Am Soc Nephrol. 2014.

3. Stone NJ, Robinson JG, Lichtenstein AH, et al. Treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease risk in adults: synopsis of the 2013 American College of Cardiology/American Heart Association cholesterol guideline. Ann Intern Med. 2014;160(5):339-343.

4. Herrington W, Emberson J, Staplin N, et al. The effect of lowering LDL cholesterol on vascular access patency: post hoc analysis of the Study of Heart and Renal Protection. Clin J Am Soc Nephrol.2014;9(5):914-919.