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    Michael L. Aaronson, MD
    Kidney Doctor and High Blood Pressure Specialist
    7401 O Street Lincoln, NE 68510
    Phone: 402-484-5600

    Sunday, April 21, 2019

    Should Patients with Chronic Kidney Disease Take Cholesterol Lowering Medication?

    Graph shows the trend of total Lipitor / Atorvastatin prescriptions written over time. In 2016, 99,942,508 prescriptions for this statin were ordered. Notice the increased trend of use over time. Also note that this statin is the third most written medication in the United States based on total scripts written by providers.

    I received a question the other day regarding which patients with chronic kidney disease should be treated with cholesterol lowering medication, such as a statin. The answer is complex, keeps changing, and differs with respect to expert opinion. That said, let's give some basic recommendations that you might consider talking with your primary provider about.

    Please note: This blog will discuss the use of cholesterol lowering medication in the setting of chronic kidney disease -- not patients on dialysis. That is a separate topic.

    First: You must realize the purpose of cholesterol lowering, or better stated LDL (or bad cholesterol) lowering therapy. The ultimate goal is to decrease the risk of having a heart attack or other cardiovascular risk conditions such as a  stroke.

    Second: Statin therapy is usually the initial therapy to lower LDL or bad cholesterol. A common statin, atorvastatin (also known as Lipitor), is the third most written statin in America and has shown benefits in patients with chronic kidney disease.

    Figure: The following figure shows the benefits of higher dosage versus lower dosage statins in patients with chronic kidney disease at baseline:

    Higher dose statin therapy using atorvastatin, also known as Lipitor, can reduce cardiovascular events in patients with CKD.

    Highlighted in yellow are  patients with chronic kidney disease (CKD). The yellow arrow points to the patients who were on a low dose of atorvastatin at 10 mg daily. 15 percent of these patients had a major cardiovascular event over the period of the study.

    Compare this to the orange arrow which represents patients with CKD on a higher dose of atorvastatin at 80 mg daily. Around 10 percent of these patients had a major cardiovascular event over the period of the study.

    The study results show a 4.1 percent absolute risk reduction in having a cardiovascular event if a patient with chronic kidney disease was taking the higher dose atorvastatin instead of the lower dose atorvastatin! That is impressive.

    There are a couple of things to think about:

    • This is just one study and there are thousands of them. So consider the information with a "grain of salt," in the context of all the literature out there.
    • Next, notice how no one was on a placebo or without statin lowering therapy. Imagine what their risk would have been without the protection of a statin.
    • I would consider having chronic kidney disease similar to having diabetes and put people with CKD at high risk for having a heart event in the future
      • Notice how patients with CKD at baseline using 80 mg of atorvastatin have similar outcomes to patients with normal kidney function who took the lower dose of atorvastatin at 10 mg. 
    Here are some considerations to manage your bad cholesterol to improve your cardiovascular health if you have CKD: (this is opinion based and the goals keep changing)

    Lower is better. All patients with CKD should be on therapy if possible given the risk of heart disease in these patients. Some patients are unable to tolerate higher doses of statins. When this occurs, the add-ons become paramount to help prevent heart disease.  Ezetimibe (also known as Zetia) can be added to statins when indicated to achieve target. What is target? Some say less than 70 for LDL.  Others suggest 50 or less.

    I have seen such complex recommendations for both primary and secondary prevention with respect to cholesterol treatment. In my opinion, it prevents us from seeing the forest from the trees. KISS: Which means keep it simple, silly! Let's do that.

    Do you have more questions? Ask your primary provider for an opinion with respect to your specific situation.