Rosuvastatin and cardiovascular events in patients undergoing hemodialysis

Disorders of lipid metabolism and chronic kidney disease in the elderly

The growing population of elderly with chronic kidney disease (CKD) is at greater risk for cardiovascular disease given an independent risk of CKD, as well as from added dyslipidemia of aging and renal dysfunction. Changes in lipid metabolism with more isodense and high-dense, triglyceride-rich particles, low high-density lipoprotein cholesterol, and increased triglyceride levels occur with CKD and aging, which are noted to have significant atherogenic potential. In addition, lipid abnormalities may lead to the progression of CKD. Cardiovascular mortality in the end-stage renal disease population is more than 10 times higher than the general population. Treatment of dyslipidemia in the general population suggests important benefits both in reducing cardiovascular risk and in the prevention of cardiovascular disease. Secondary analyses of elderly subgroups of various large prospective studies with statins suggest treatment benefit with statin use in the elderly. Similarly limited data from secondary analyses of CKD subgroups of larger prospective trials using statins also suggest a possible benefit in cardiovascular outcomes and the progression of kidney disease. However, randomized trials have yet to confirm similar benefits and targets of treatment for dyslipidemia in the elderly with CKD and end-stage renal disease. Treatment in the elderly with CKD should be individualized and outweigh risks of side effects and drug-drug interactions. There is a need for further specific investigation of dyslipidemia of CKD in the aging population in relation to renal disease progression and cardiovascular outcome.

Uremic toxicity, oxidative stress, and hemodialysis as renal replacement therapy

Patients with uremia are subject to greatly increased cardiovascular risk that cannot be completely explained by traditional cardiovascular risk factors. An increase in oxidative stress and inflammation has been proposed as contributory nontraditional uremic cardiovascular risk factors. Oxidative stress reflects the balance between oxidant generation and antioxidant defense mechanisms. Reduction/oxidation (redox) reactions may result in a stochastic process leading to oxidation of neighboring macromolecules. However, in many instances the reactive oxygen species target particular amino acid residues or lipid moieties. This provides a mechanism by which increased oxidative stress and/or alteration of antioxidant mechanisms can alter cell signaling. In individuals with advanced chronic kidney disease, the redox balance is not in equilibrium and is tipped toward oxidation resulting in the dysregulation of cellular process with subsequent vascular and tissue injury. In this review, the major oxidant and antioxidant pathways and the biomarkers to assess redox status in uremia are discussed, as well as the data linking the pathogenesis of oxidative stress, inflammation, cardiovascular events, and the progressive loss of kidney function in chronic kidney disease.

Impact of managing atherogenic dyslipidemia on cardiovascular outcome across different stages of diabetic nephropathy

IMPORTANCE OF THE FIELD

The prevalence of chronic kidney disease (CKD) and type 2 diabetes mellitus (T2DM) is increasing. In turn, both CKD and T2DM are associated with increased risk of vascular events and progression to end-stage kidney disease (ESKD). In patients with DM, statin treatment can significantly improve estimated glomerular filtration rate (eGFR) or delay eGFR decline as well as significantly reduce CVD morbidity and mortality. In contrast, statins do not seem to decrease events in patients with advanced decline in kidney function.

AREAS COVERED IN THIS REVIEW

This review considers the effects of statins and other lipid lowering drugs on kidney function and vascular events in patients with CKD and T2DM.

WHAT THE READER WILL GAIN

Greater awareness of the links between CKD, T2DM, kidney function and vascular risk as well as the role of lipid-lowering drugs (mainly statins) in this field.

TAKE HOME MESSAGE

Current evidence points towards the need to prescribe statins in patients with T2DM before a major decline in kidney function occurs.

Glycemic control and the risk of death in 1,484 patients receiving maintenance hemodialysis

BACKGROUND

It is controversial whether tighter glycemic control is associated with better clinical outcomes in people with kidney failure. We aim to determine whether worse glycemic control, measured using serum glucose and hemoglobin A(1c) (HbA(1c)) levels, is independently associated with higher mortality in patients undergoing maintenance hemodialysis.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

1,484 patients starting maintenance hemodialysis therapy in Alberta, Canada, between 2001 and 2007.

PREDICTOR

Serum glucose and HbA(1c) levels.

OUTCOME

All-cause mortality.

MEASUREMENTS

Monthly casual glucose levels from specimens drawn immediately before the first dialysis treatment were averaged over 3 months before and after hemodialysis therapy initiation. Similarly, monthly HbA(1c) values in patients with or at risk of diabetes were averaged.

RESULTS

Overall, median age was 66 years, 41% were women, 75% were white, and 55% had diabetes. All-cause mortality during 8 years (median, 1.5 years) was 43%; it was 49% in those with diabetes. There was no relation between average glucose level and mortality in unadjusted analysis (HR, 1.00 per 18 mg/dL [1 mmol/L]; P = 0.4) or after adjustment for confounders (HR, 0.98 per 18 mg/dL; 95% CI, 0.96-1.01; P = 0.2). Higher HbA(1c) level was not associated with mortality when analyzed in the unadjusted analysis (HR, 1.01 per 1% HbA(1c); P = 0.9) or after adjustment for confounders (HR, 0.98 per 1% HbA1c; 95% CI, 0.88-1.08; P = 0.7). Results were similar when HbA(1c) values were divided into prespecified categories (adjusted P > 0.6 for trend). Markers of malnutrition-inflammation (albumin, hemoglobin, and white blood cell values) or the presence of diabetes did not influence the relation between glycemic control and death (all P for interaction > 0.2).

LIMITATIONS

Registry data; casual serum glucose measurements; HbA(1c) values available for only a subset of participants.

CONCLUSIONS

Higher casual glucose and HbA(1c) levels were not associated with mortality in maintenance hemodialysis patients with or without diabetes. This may have implications for recommended glycemic targets, quality indicators, and how best to assess glycemic control in this high-risk population.

Modeling the 4D Study: statins and cardiovascular outcomes in long-term hemodialysis patients with diabetes

BACKGROUND AND OBJECTIVES

Randomized, controlled trials (RCTs) are the gold standard for defining causal inferences but are sometimes not feasible because of cost, ethical, or time considerations. We explored the accuracy and potential use of a "simulated trial" through the modeling of a previously published RCT, Die Deutsche Diabetes Dialyse Studie (4D Study), a landmark study that investigated the cardiovascular benefit of atorvastatin use in 1255 patients with ESRD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using a large historical database of interventions and outcomes in dialysis patients, we conducted an observational model of the 4D Study in dialysis patients who had type 2 diabetes and were prescribed a statin (5144 patients) and matched to a non-statin user (5144 control subjects) before multivariate modeling. Inclusion, exclusion, and outcome parameters of the study, as prespecified by the 4D Study, were strictly modeled in this analysis.

RESULTS

In covariate- and propensity-adjusted Cox regression, statin use (versus nonuse) was associated with a decrease in the composite primary outcome of cardiac death, nonfatal myocardial infarction, and stroke. Statin use was also associated with a decrease in cardiovascular mortality and all cardiac events combined. The hazard ratios in this observational model were numerically comparable to the hazard ratios reported in the 4D Study; however, because of the larger number of patients "enrolled," results in this simulated study achieved statistical significance.

CONCLUSIONS

Statin use was associated with some cardiovascular benefit in a simulated trial of patients with ESRD; however, the size of benefit was considerably smaller than that seen in the general population. Such simulated trials may represent an exploratory, cost-effective option when RCTs are not immediately feasible.

HDL metabolism and activity in chronic kidney disease

Chronic kidney disease (CKD) is associated with development of atherosclerosis and premature death from cardiovascular disease. The predisposition of patients with CKD to atherosclerosis is driven by inflammation, oxidative stress and dyslipidemia, all of which are common features of this condition. Markers of dyslipidemia in patients with advanced CKD are impaired clearance and heightened oxidation of apolipoprotein-B-containing lipoproteins and their atherogenic remnants, and a reduction of the plasma concentration, antioxidant, and anti-inflammatory properties of high-density lipoprotein (HDL). Studies in animal models of CKD indicate that the disease promotes lipid accumulation in the artery wall and kidney, leading to atherosclerosis, glomerulosclerosis and tubulointerstitial injury. These effects seem to be mediated by an increased cellular influx of lipids, elevated cellular production and reduced cellular catabolism of fatty acids, and impaired antioxidant, anti-inflammatory and reverse lipid transport properties of HDL. Available pharmacological therapies have been largely ineffective in ameliorating oxidative stress, inflammation, HDL deficiency and/or dysfunction, and the associated atherosclerosis and cardiovascular disease in patients with end-stage renal disease. This Review aims to provide an overview of the mechanisms and consequences of CKD-induced HDL deficiency and dysfunction.

Cardiovascular risk factors underestimate atherosclerotic burden in chronic kidney disease: usefulness of non-invasive tests in cardiovascular assessment

BACKGROUND

Cardiovascular risk scoring (Score) does not specifically address chronic kidney disease (CKD) patients. The aim of our study is to quantify atherosclerosis using carotid ultrasound and ankle-brachial index (ABI) and to assess its additional value in risk scoring.

METHODS

In this cross-sectional, observational study, patients were studied according to a standardized protocol including carotid ultrasound and ABI to determine the atherosclerosis score (AS), ranging from absence of to severe atherosclerosis (AS 0 to AS 3).

RESULTS

We included 409 CKD-affected patients (231 on dialysis, 99 in CKD Stages IV-V and 79 in CKD Stages I-III) and 851 subjects with normal renal function. The presence and severity of atherosclerosis was significantly higher in the CKD group than in the controls at every decade of age studied. Among the CKD-affected subjects, the prevalence of carotid plaques was significantly higher in the dialysis group (78.3%) than in the group in CKD Stages I-III (55.6%, P < 0.001). We identified 174 patients at low-intermediate risk. Among them, 110 (63.2%) presented either moderate (AS 2) or severe (AS 3) atherosclerosis. Variables significantly (P < 0.05) and positively related to atherosclerosis were being on dialysis [OR = 3.40, 95% CI (1.73, 6.78) vs CKD Stages I-III], age [OR = 1.08, 95% CI (1.06-1.11)] and C-reactive protein [OR = 1.04, 95% CI (1.01-1.08)]. Conversely, female sex was negatively related to atherosclerosis [OR = 0.40, 95% CI (0.23-0.71), P = 0.002].

CONCLUSION

The use of carotid ultrasound and ABI identifies atherosclerosis in a population of CKD patients in which risk scoring underestimates atherosclerosis burden.

Statin treatment for patients with heart failure

Statins may be beneficial for the prevention and treatment of heart failure, as indicated by large observational studies, small prospective studies, and post hoc analyses of cardiovascular databases. Two large, prospective, controlled trials have, however, shown that rosuvastatin has neutral effects on the survival of patients with chronic heart failure. The benefits of statin treatment seem to mostly result from their ability to halt disease progression in heart failure, particularly in patients with coronary artery disease. Based on these results, statin treatment might only be useful for the prevention of heart failure, and possibly in patients with new-onset heart failure. This Review highlights data from observational data analyses as well as from the large prospective trials investigating the safety and efficacy of statins in patients with heart failure. The results from these studies and their implications for the timing of initiating statin therapy in this patient population are also discussed.

Persistent inflammation as a catalyst for other risk factors in chronic kidney disease: a hypothesis proposal

Because inflammation by now is a "traditional" finding that predicts poor outcome and cardiovascular events in the vast majority of patients with ESRD, it could be argued that inflammatory biomarkers should not longer be considered "novel" risk factors. In this review, we forward the hypothesis that, in addition to putative direct proatherogenic effects, persistent inflammation may serve as a catalyst and, in the toxic uremic milieu, modulate the effects of other concurrent vascular and nutritional risk factors. We discuss some recent observational studies, suggesting that the presence of persistent inflammation magnifies the risk for poor outcome via mechanisms related to self-enhancement of the inflammatory cascade and exacerbation of both the wasting and the vascular calcification processes. Because persistent inflammation may be the silent culprit of other commonly observed pathophysiologic alterations in chronic kidney disease, it is imperative that inflammatory markers be regularly monitored and therapeutic attempts be made to target persistent low-grade inflammation in this patient group.

Left ventricular mass in chronic kidney disease and ESRD

Chronic kidney disease (CKD) and ESRD, treated with conventional hemo- or peritoneal dialysis are both associated with a high prevalence of an increase in left ventricular mass (left ventricular hypertrophy [LVH]), intermyocardial cell fibrosis, and capillary loss. Cardiac magnetic resonance imaging is the best way to detect and quantify these abnormalities, but M-Mode and 2-D echocardiography can also be used if one recognizes their pitfalls. The mechanisms underlying these abnormalities in CKD and ESRD are diverse but involve afterload (arterial pressure and compliance), preload (intravascular volume and anemia), and a wide variety of afterload/preload independent factors. The hemodynamic, metabolic, cellular, and molecular mediators of myocardial hypertrophy, fibrosis, apoptosis, and capillary degeneration are increasingly well understood. These abnormalities predispose to sudden cardiac death, most likely by promotion of electrical instability and re-entry arrhythmias and congestive heart failure. Current treatment modalities for CKD and ESRD, including thrice weekly conventional hemodialysis and peritoneal dialysis and metabolic and anemia management regimens, do not adequately prevent or correct these abnormalities. A new paradigm of therapy for CKD and ESRD that places prevention and reversal of LVH and cardiac fibrosis as a high priority is needed. This will require novel approaches to management and controlled interventional trials to provide evidence to fuel the transition from old to new treatment strategies. In the meantime, key management principles designed to ameliorate LVH and its complications should become a routine part of the care of the patients with CKD and ESRD.

Biochemistry and biomarkers of inflamed patients: why look, what to assess

Specific laboratory tests and physical findings are available to the practicing clinician that should raise the suspicion of inflammation. Inflammation is related to specific clinical outcomes. Once identified, changes in clinical practice may affect the level of inflammation in individual and or groups of dialysis patients with the hope that these changes may in turn affect outcome in a positive manner. Standard clinical tests and observations associated with inflammation are hypoalbuminemia, erythropoietin resistance, decreased iron saturation accompanied by high ferritin, frailty, low serum creatinine, reduced total and LDL-cholesterol, and increased C reactive protein (CRP). Inflammation is strongly associated with loss of physical function, dyslipidemia (low LDL- and HDL-cholesterol, increased triglycerides), and anemia that is unresponsive to erythropoietin. Inflammation is associated with cardiovascular events, increased hospitalization, and death. Correctible causes of inflammation are tunneled dialysis catheters, arteriovenous grafts, catheter infection, periodontal disease, poor water quality, and dialyzer incompatibility. Obesity also is a source of cytokines but may be less amenable to treatment. Inflammation is multifactorial in dialysis patients. Some sources are recognizable and correctable, such as vascular access type, clinical infection, and water quality, and some are not. Inflammation is strongly associated with outcome.

Vasculotropic effects of calcimimetics

PURPOSE OF REVIEW

At all stages of chronic kidney disease (CKD) cardiovascular death is the most prominent cause of mortality. Current treatment options are still not completely satisfactory in this group of high cardiovascular risk patients. Experimental data and clinical observations suggest a role of secondary hyperparathyroidism, hyperphosphatemia, and hypercalcemia in the genesis of cardiovascular complications of CKD. The ubiquitous expression of the calcium-sensing receptor, which is targeted by calcimimetics and the pleiotropic effects of calcimimetics, make this class of drugs potential candidates for cardiovascular intervention.

RECENT FINDINGS

Recent experimental studies suggest that calcimimetics interfere with the development of vascular abnormalities in CKD and to some extent even reverse them. The effects of calcimimetics on the vasculature are, at least partially, independent of their effects on calcemia, phosphatemia, and parathyroid hormone concentration. The beneficial effects of calcimimetics on vascular calcification, arteriolar thickening, atherogenesis, and myocardial capillarization are well documented. In addition they have hypotensive and renoprotective actions.

SUMMARY

Experimental models suggest beneficial effects of calcimimetics on cardiovascular disease. Although prospective clinical data are still lacking, retrospective data suggest cardiovascular benefit of calcimimetics even in humans. Clinical trials with calcimimetics evaluating hard cardiovascular end-points would be desirable.

Efficacy of rosuvastatin among men and women with moderate chronic kidney disease and elevated high-sensitivity C-reactive protein: a secondary analysis from the JUPITER (Justification for the Use of Statins in Prevention-an Intervention Trial Evaluating Rosuvastatin) trial

OBJECTIVES

We evaluated the efficacy of statin therapy in primary prevention among individuals with moderate chronic kidney disease (CKD).

BACKGROUND

Whether patents with moderate CKD (estimated glomerular filtration rate [eGFR] <60 ml/min/1.73 m(2)) benefit from statin therapy is uncertain, particularly among those without hyperlipidemia or known cardiovascular disease.

METHODS

Within the JUPITER (Justification for the Use of statins in Prevention-an Intervention Trial Evaluating Rosuvastatin) primary prevention trial of rosuvastatin 20 mg compared with placebo among men and women free of cardiovascular disease who had low-density lipoprotein cholesterol (LDL-C) <130 mg/dl and high-sensitivity C-reactive protein (hsCRP) >or=2 mg/l, we performed a secondary analysis comparing cardiovascular and mortality outcomes among those with moderate CKD at study entry (n = 3,267) with those with baseline eGFR >or=60 ml/min/1.73 m(2) (n = 14,528). Median follow-up was 1.9 years (maximum 5 years).

RESULTS

Compared with those with eGFR >or=60 ml/min/1.73 m(2), JUPITER participants with moderate CKD had higher vascular event rates (hazard ratio [HR]: 1.54, 95% confidence interval [CI]: 1.23 to 1.92, p = 0.0002). Among those with moderate CKD, rosuvastatin was associated with a 45% reduction in risk of myocardial infarction, stroke, hospital stay for unstable angina, arterial revascularization, or confirmed cardiovascular death (HR: 0.55, 95% CI: 0.38 to 0.82, p = 0.002) and a 44% reduction in all-cause mortality (HR: 0.56, 95% CI: 0.37 to 0.85, p = 0.005). Median LDL-C and hsCRP reductions as well as side effect profiles associated with rosuvastatin were similar among those with and without CKD. Median eGFR at 12 months was marginally improved among those allocated to rosuvastatin as compared with placebo.

CONCLUSIONS

Rosuvastatin reduces first cardiovascular events and all-cause mortality among men and women with LDL-C <130 mg/dl, elevated hsCRP, and concomitant evidence of moderate CKD. (JUPITER-Crestor 20 mg Versus Placebo in Prevention of Cardiovascular [CV] Events; NCT00239681).

[Cardiorenal syndrome]

With increasing age of a population, the rate and severity of comorbidities are also growing, resulting in a rising number of people with a condition described as "cardiorenal syndrome". Initially, cardiorenal syndrome defined the decline in cardiac and renal function due to diminished renal perfusion in the context of heart failure. However, in order to give consideration to the numerous comorbidities, nowadays the definition has been widened. Following a new classification, five types of cardiorenal syndrome are distinguished. Such a differentiation is helpful to find the appropriate therapeutic approach, according to the underlying disease. Therefore, the new classification and modern therapeutic concepts shall be presented here.

The effects of rosuvastatin on the serum cortisol, serum lipid, and serum mevalonic acid levels in the healthy Indian male population

In this open-label, balanced, randomized, placebo-controlled, parallel study, healthy male volunteers were randomly divided into two groups. Each group received either a single oral dose of rosuvastatin 20 mg or placebo. Estimations were done at predose on day 1 of dosing (baseline) and 24 h postdose after days 7 and 14. Serum cortisol and serum lipid levels were estimated using enzyme-linked immunosorbent assay kits and serum mevalonic acid (MVA) levels were measured using validated liquid chromatography-tandem mass spectrometry method. Rosuvastatin produced a statistically significant (P < 0.05) decrease in total cholesterol, low-density lipoprotein cholesterol, very low-density lipoprotein cholesterol, and triglycerides. However, the increase in high-density lipoprotein cholesterol and decrease in cortisol and MVA were not statistically significant when compared to the placebo-treated group. The study showed that rosuvastatin at a dose of 20 mg/day for a period of 14 days was very potent as cholesterol-lowering agent, without any significant change in serum cortisol level in the healthy Indian male population.

A randomized, controlled trial of simvastatin versus rosuvastatin in patients with acute myocardial infarction: the Secondary Prevention of Acute Coronary Events--Reduction of Cholesterol to Key European Targets Trial

AIMS

We sought to evaluate reports that rosuvastatin 10 mg is a more efficacious treatment of hyperlipidaemia than is simvastatin 40 mg, hoping to assess this issue in the previously unstudied context of acute myocardial infarction.

METHODS AND RESULTS

The Secondary Prevention of Acute Coronary Events - Reduction of Cholesterol to Key European Targets (SPACE ROCKET) Trial was an investigator-led, open-label, blinded-endpoint, multicentre, randomized, controlled trial assessing the proportion of patients, at 3 months, achieving European Society of Cardiology 2003 (ESC-03) lipid targets of total cholesterol (TC) less than 4.5 mmol/l (174 mg/dl) or low-density lipoprotein cholesterol (LDLc) less than 2.5 mmol/l (97 mg/dl). Of 1263 patients randomized, 77.6% simvastatin versus 79.9% rosuvastatin achieved ESC-03 targets [odds ratio (OR): 1.16; 95% confidence interval (CI): 0.88-1.53; P = 0.29]. There were statistically significant differences for simvastatin versus rosuvastatin, respectively, for mean LDLc 2.03 mmol/l (78 mg/dl) versus 1.94 mmol/l (75 mg/dl; P = 0.009) and also mean TC 3.88 mmol/l (150 mg/dl) versus 3.75 mmol/l (145 mg/dl; P = 0.005). A post-hoc analysis showed higher achievement of the new ESC, American Heart Association and American College of Cardiology optimal lipid target of LDLc less than 1.81 mmol/l (70 mg/dl) with rosuvastatin (45.0%) compared with simvastatin (37.8%; OR: 1.37; 95% CI: 1.09-1.72; P = 0.007). The proportion of patients achieving the Fourth Joint Task Force European Guidelines (2007) of TC less than 4.0 mmol/l (155 mg/dl) and LDLc less than 2.0 mmol/l (77 mg/dl) was 38.7% for simvastatin 40 mg and 47.7% for rosuvastatin 10 mg (OR: 1.48; 95% CI: 1.18-1.86; P = 0.001).

CONCLUSION

We observed no superiority of either treatment for the ESC-03 lipid targets. Rosuvastatin 10 mg lowered mean cholesterol more effectively than simvastatin and achieved better results for the latest, more stringent, ESC target.

Sevelamer and the bone-vascular axis in chronic kidney disease: bone turnover, inflammation, and calcification regulation

Hyperphosphatemia is a central characteristic feature of chronic kidney disease-mineral and bone disorder (CKD-MBD). Phosphorus excess is an independent cardiovascular risk factor for morbidity and mortality in patients with advanced CKD. Over the past 40 years, hyperphosphatemia has been a central therapeutic issue in advanced CKD. Mainstays of hyperphosphatemia treatment are reduction of dietary phosphorus, use of phosphate binders, and optimized phosphorus removal via dialysis. Currently, several phosphate binders are approved for use (aluminum, calcium, lanthanum, sevelamer); all share a common functionality in that they bind phosphorus and reduce the amount absorbed in the gastrointestinal lumen. Over the last decade, nephrologists have debated the relative tolerability and efficacy of these agents, especially the potential for vascular calcification and cardiovascular risk reduction. Recent research has focused on the question of whether a metal-free, calcium-free, and non-absorbed binder, such as sevelamer, offers advantages over other binder types. Most notable may be the potential benefit of reducing calcium load. In addition, sevelamer has several additional pleiotropic effects that may extend its basic indication, some of which may help attenuate vascular calcification. These include effects on bone turnover and the link between abnormal vascular processes and bone metabolism (the so-called 'bone-vascular axis'), as well as lipid metabolism, and systemic inflammatory mediators such as fetuin-A. We review the evidence for these pleiotropic effects, and suggest these may help in some way to improve the substantial disease burden in the CKD-MBD population.

Rosuvastatin along the cardiovascular continuum: from JUPITER to AURORA

Dyslipidemia is one of the major causes of atherosclerosis, although in the last few years an increase in cholesterol control rates has been reported. However, results from the European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) surveys indicate that approximately 50% of the patients with ischemic heart disease still do not attain LDL-cholesterol goals despite the use of lipid-lowering therapy (including statins). Rosuvastatin is a new and potent statin that produces greater reductions of LDL-cholesterol when compared with other agents in this class. Furthermore, rosuvastatin provides additional benefits in the lipid profile such as increased HDL-cholesterol, and decreased triglycerides, total cholesterol, apolipoprotein B and apolipoprotein B:A-1 ratio. Cardiovascular disease is a continuum: from risk factors to subclinical organ damage and finally to overt clinical cardiovascular disease. Several trials have investigated the effects of rosuvastatin along this cardiovascular continuum. The results provided by the GALAXY program emphasize the importance of the early treatment with rosuvastatin in the cardiovascular continuum to achieve the greatest benefit. In this paper, the efficacy and safety of rosuvastatin along the cardiovascular continuum is reviewed.

Cardiovascular complications in diabetic kidney disease

Diabetes mellitus (DM) is the leading cause of chronic kidney disease (CKD). Due to an explosion in the incidence and the prevalence of Type 2 DM, the burden of CKD is expected to increase proportionately. Both DM and CKD are associated with a high incidence of cardiovascular (CV) morbidity and mortality, and it is important to understand the unique nature of CV disease in patients with the combination of these two conditions. In this report, we review the traditional and nontraditional risk factors that underlie the high risk of CV disease in this population, with a particular focus on vascular calcification, mineral metabolism, and therapeutic paradigms for the treatment of cardiovascular disease in this unique and high-risk population.

The pro-inflammatory effect of uraemia overrules the anti-atherogenic potential of immunization with oxidized LDL in apoE-/- mice

BACKGROUND

Uraemia increases oxidative stress, plasma titres of antibodies recognizing oxidized low-density lipoprotein (oxLDL) and development of atherosclerosis. Immunization with oxLDL prevents classical, non-uraemic atherosclerosis. We have investigated whether immunization with oxLDL might also prevent uraemia-induced atherosclerosis in apolipoprotein E knockout (apoE-/-) mice.

METHODS

ApoE-/- mice were immunized with either native LDL (n = 25), Cu(2+)-oxidized LDL (n = 25), PBS (n = 25), the apolipoprotein B-derived peptide P45 (apoB-peptide P45) conjugated to bovine serum albumin (BSA) (n = 25) or BSA (n = 25) prior to induction of uraemia by 5/6 nephrectomy (NX).

RESULTS

Immunization with oxLDL increased plasma titres of immunoglobulin G (IgG) recognizing Cu(2+)-oxLDL and malondialdehyde-modified LDL (MDA-LDL). However, 5/6 NX induced a marked increase in plasma concentrations of anti-oxLDL antibodies as well as pro-atherogenic cytokines [interleukin (IL)-2 (IL-2), IL-4, IL-6 and IL-12)] in native mouse LDL (nLDL)-, oxLDL- and PBS-immunized mice. Even though nLDL- and oxLDL-immunized mice displayed higher anti-MDA-LDL IgG titres than the PBS group, aortic atherosclerosis lesion size was not affected by immunization. Immunization with the apoB-peptide P45, which consistently reduces classical atherosclerosis in non-uraemic mice, also did not reduce lesion size in uraemic apoE-/- mice.

CONCLUSION

The results suggest that the pro-inflammatory and pro-atherogenic effect of uraemia overrules the anti-atherogenic potential of oxLDL immunization in apoE-/- mice.

Prediction of cardiovascular event risk reduction from lipid changes associated with high potency dyslipidemia therapy

BACKGROUND

Epidemiological data suggests for every 1% reduction in LDL-C there is a corresponding 1-1.5% reduction in cardiovascular events (CVEs). Additionally, for every 2-3% increase in HDL-C there is a reduction in CVEs by 2-4% that is independent of LDL-C. With numerous treatment options for managing dyslipidemia, it is important to evaluate agents that result in the greatest reduction of CVEs.

OBJECTIVE

To compare current high-potency dyslipidemia pharmacotherapy with respect to changes in LDL-C and HDL-C and estimate risk reductions for CVEs.

METHODS

This study is an analysis of existing published studies for dyslipidemia products marketed in the US. Literature searches were conducted using Medline, International Pharmaceutical Abstracts, Embase, and CINAH to identify trials for niacin extended-release and lovastatin (NER/L); niacin extended-release and simvastatin (NER/S); rosuvastatin (R); and, ezetimibe/simvastatin (E/S) from database inception to 1 May 2009. Demographics and changes from baseline in LDL-C and HDL-C were abstracted and HDL-C to LDL-C change (%Delta-lipids) was created for each therapy. Using a previously validated model the percent reduction in CVEs was estimated for each treatment strategy.

RESULTS

Data for 177 treatment arms (120 unique reports), accounting for drug and dose were abstracted. The range in mean +/- SD %Delta-lipids depending on drug dose was: E/S, 58 +/- 6 to 67 +/- 3; R, 51 +/- 5 to 65 +/- 5; NER/L, 33 +/- 7 to 75 +/- 7; and NER/S, 48 to 77 +/- 4. Risk reductions were greatest for NER/statin combinations, with percent risk reductions greater than 77% for NER/S, 2000 mg/10 mg and 83% NER/S, 2000 mg/40 mg. Ignoring medication strengths, reductions in CVEs ranged from 58% for R, 60% for E/S, 61% for NER/L, and 72% for NER/S.

LIMITATIONS

There are several potential limitations associated with this study including: publication bias, English only search, limited published studies with NER in combination with L or S, adherent populations, and aggregation of multiple populations.

CONCLUSION

The results of the analysis suggest that greater risk reductions in CVEs occur with combination therapies, especially those including niacin extended-release (NER). Up to an 83% risk reduction was estimated for the highest doses of NER and simvastatin (NER/S).

Steroid avoidance or withdrawal after renal transplantation increases the risk of acute rejection but decreases cardiovascular risk. A meta-analysis

INTRODUCTION

The morbidity related to long-term steroid therapy has led to continued interest in withdrawal of steroids from immunosuppressant regimens after renal transplantation. A number of recent trials have provided long-term information regarding the risks and benefits of steroid avoidance or withdrawal (SAW).

METHODS

A literature search was performed using Ovid Medline, Embase, the Cochrane Library, and the Transplant Library. Randomized controlled trials comparing a maintenance steroid group with complete avoidance or withdrawal of steroids were selected. All studies were assessed for methodological quality. Trials were pooled by meta-analysis to provide summary effects (relative risk [RR] or weighted mean difference) with 95% confidence intervals (CI).

RESULTS

Thirty-four studies including 5,637 patients met the inclusion criteria. SAW regimens significantly increased the risk of acute rejection (AR) over maintenance steroids (RR 1.56, CI 1.31-1.87, P<0.0001). No significant differences in corticosteroid resistant AR, patient survival, or graft survival were observed. Serum creatinine was increased and creatinine clearance was reduced with SAW. Cardiovascular risk factors including incidence of hypertension (RR 0.90, CI 0.85-0.94, P<0.0001), new onset diabetes (RR 0.64, CI 0.50-0.83, P=0.0006), and hypercholesterolemia (RR 0.76, CI 0.67-0.87, P<0.0001) were reduced significantly by SAW.

CONCLUSION

Despite an increase in the risk of AR with SAW protocols, there is only a small effect on graft function with no measurable effect on graft or patient survival. There are significant benefits in cardiovascular risk profiles after SAW. SAW protocols would seem justified with current immunosuppressive protocols in low-risk recipients.

Clinical presentation of renal failure in the aged: chronic renal failure

Chronic kidney disease is increasingly being recognized in elderly individuals across the world. An understanding of the methods used to estimate or to measure kidney function, the likelihood and factors associated with progressive decline in renal function, and the clinical syndromes associated with poor renal function are key topics for individuals working across many medical disciplines. This review addresses some of the important aspects of chronic kidney disease, and summarizes some of the clinical and laboratory features associated with progressive disease.

Efficacy and safety of ezetimibe in patients undergoing hemodialysis

Patients with dyslipidemia and advanced renal failure are at markedly increased risk of cardiovascular morbidity and mortality. We evaluated the efficacy and safety of ezetimibe administration to patients with endstage renal failure (ESRF) who are undergoing hemodialysis. Ezetimibe at 10 mg/day was given to 20 patients for 12 weeks. Efficacy was determined by monitoring lipids, and safety was determined by monitoring clinical and laboratory parameters. We also evaluated the effects of ezetimibe on surrogate markers of cholesterol absorption and synthesis. Compared to baseline values, LDL-cholesterol (LDL-C) was reduced by 24.9% (p<0.005) after 12 weeks of ezetimibe administration. Treatment with ezetimibe did not change HDL-cholesterol, triglyceride and HbA1c values but caused a significant reduction in remnant like particles-cholesterol (RLP-C, p<0.05) and high-sensitive C-reactive protein (hsCRP, p<0.05). Ezetimibe therapy decreased cholesterol absorption markers (campesterol and sitosterol) and increased a marker of cholesterol synthesis (lathosterol). A highly significant correlation was observed between alterations in LDL-C and campesterol levels in response to ezetimibe therapy. No patients reported musculoskeletal symptoms. None of the patients experienced elevations in their creatine kinase or liver transaminase levels. Ezetimibe not only reduced serum LDL-C, but also RLP-C and hsCRP, in ESRF patients. Inhibition of cholesterol absorption by ezetimibe is an important therapeutic option in these patients due to its efficacy and safety.