Statins Beneficial in Wide Range of Patients With CKD-

[kickingandscreaming]

www.medscape.com
 
Statins Beneficial in Wide Range of Patients With CKD

Veronica Hackethal, MDAugust 08, 2016

Statins decrease major cardiovascular events in mild to moderate chronic kidney disease (CKD). However, these benefits decrease with declining kidney function and may not apply to dialysis patients, according to a meta-analysis published online July 28 in Lancet Diabetes & Endocrinology.

The data suggest statins may benefit a "wide range" of patients with CKD. "In patients with [CKD], statin-based regimens should be chosen to maximise the absolute reduction in [low-density lipoprotein (LDL)] cholesterol to achieve the largest treatment benefits," write the authors, who were part of the Cholesterol Treatment Trialists' (CTT) Collaboration.

However, the results are not with some caveats.

"Our results show that, even after allowing for somewhat smaller reductions in LDL cholesterol as [glomerular filtration rate (GFR)] declines, there is a trend towards smaller relative risk reductions for major coronary events and strokes. In particular, there was little evidence that statin-based therapy was effective in patients starting treatment after dialysis had been initiated," they write.

The study also highlighted that the greater the LDL reduction, the larger the benefit of statins. Achieving greater LDL reduction, however, generally means higher statin doses, which may increase the risk for myopathy in some patients with renal impairment.

The researchers drew on data from the CTT Collaboration clinical trials database and encompassed 28 trials covering 183,419 individuals, including those on dialysis and kidney transplant patients. The analysis included AURORA, a key trial of dialysis patients. Because the AURORA trial used a different definition for coronary death than other trials, researchers reclassified this outcome to standardize assessment. They also standardized results to account for differences in the amount of LDL reduction across trials.

Overall, results showed that statins decreased the risk of having a first major vascular event by 21% per mmol/L decrease in LDL cholesterol (rate ratio, 0.79; 95% confidence interval [CI], 0.77 - 0.81; P < .0001). Major coronary events and stroke both decreased with statin use (rate ratio, 0.76 [95% CI, 0.73 - 0.79] and 0.84 [95% CI, 0.80 - 0.89], respectively).

The benefits of statins decreased, along with declining estimated GFR (eGFR; P = .008 for trend), mainly related to major coronary events (P = .01 for trend) and stroke (P = .07 for trend):

    eGFR ≥60 mL/minute per 1.73 m2: RR, 0.78; 99% CI, 0.75 - 0.82

    eGFR 45 to <60 mL/minute per 1.73 m2: RR, 0.76; 99% CI, 0.70 - 0.81

    eGFR 30 to <45 mL/minute per 1.73 m2: RR, 0.85; 99% CI, 0.75 - 0.96

    eGFR <30 mL/minute per 1.73 m2 and not on dialysis: RR, 0.85; 99% CI, 0.71 - 1.02

    Dialysis: RR, 0.94; 99% CI, 0.79 - 1.11

Moreover, statins decreased the risk for coronary revascularization procedures by 25% per 1.0 mmol/L decrease in LDL (RR, 0.75; 95% CI, 0.73 - 0.78; P < .0001), which was not significantly affected by baseline renal function (P = .9 for trend).

Statins also decreased vascular death by 12% per 1.0 mmol/L decrease in LDL cholesterol (RR, 0.88; 95% CI, 0.85 - 0.91; P < .0001), with smaller risk reductions in those with more impaired baseline renal function (P = .03 for trend).

Statins did not significantly affect nonvascular mortality, regardless of eGFR.

"The results provide convincing evidence that statin therapy is beneficial in a wide range of patients with chronic kidney disease, with benefits proportional to the absolute LDL cholesterol reduction achieved. They also provide further evidence that the relative risk reductions achieved for major cardiovascular events diminish in magnitude with reducing kidney function," write Muh Geot Wong, MD, PhD, and Vlado Perkovic, MD, PhD, both from the University of Sydney in Australia, in a linked editorial.

They emphasized the feasibility and importance of large clinical trials in patients with advanced CKD. In particular, they highlighted the potential cardiovascular benefits of new treatments such as PSCK9 inhibitors and studying whether statins can benefit kidney function.

"[The results from this trial] raise further questions about the effects of lipid-lowering in advanced disease and highlight the importance of new trials with highly effective agents in this population. By defining what we still do not know, this analysis will hopefully encourage further studies that improve outcomes for this high-risk patient group," they conclude.


Cite this article: Statins Beneficial in Wide Range of Patients With CKD. Medscape. Aug 08, 2016.

[MooseMom]

Well, here's one more trial that serves to highlight what we don't know! 

Still, I did not know that the efficacy of statins decrease as egfr decreases, but when you think about it, I guess that makes sense.

[OneForTheBirds]

I asked my husband and he said at the lower eGFR there wasn't enough data and the results are inconclusive.  If they had more data, the results could go either way.

[Athena]

Researching statins is one of the most confusing topics in medicine. There seem to be so many doctors and clinicians who dispute the benefits of statins, and patients who have sworn off them as there are clinical trials reporting a 'significant' positive effect on CVD.