Statins and kidney disease: is the study of heart and renal protection at the cutting edge of evidence?

Effects of Statin Use in Advanced Chronic Kidney Disease Patients

Although statin treatment is recommended for patients with chronic kidney disease (CKD) stages I⁻IV, its potential benefits have not been reported in advanced CKD patients. Non-diabetic patients with advanced CKD (pre-dialysis patients, estimated glomerular filtration rate <15 mL/min/1.73 m²) were enrolled from a National Health Insurance Research Database with a population of 23 million. Statin users and non-users were matched using propensity scoring and analyzed using Cox proportional hazards models, taking mortality as a competing risk with subsequent end-stage renal disease (ESRD) and statin doses as time-dependent variables. A total of 2551 statin users and 7653 matched statin non-users were identified from a total 14,452 patients with advanced CKD. Taking mortality as a competing risk, statin use did not increase the risk of new-onset diabetes mellitus (NODM) or decrease the risk of de novo major adverse cardiovascular events (MACE), but reduced all-cause mortality (hazard ratio (HR) = 0.59 [95% CI 0.42⁻0.84], p = 0.004) and sepsis-related mortality (HR = 0.53 [95% CI 0.32⁻0.87], p = 0.012). For advanced CKD patients, statin was neither associated with increased risks of developing NODM, nor with decreased risk of de novo MACE occurrence, but with a reduced risk of all-cause mortality, mainly septic deaths.

Statins in chronic kidney disease and kidney transplantation

HMG-CoA reductase inhibitors (statins) have been shown to improve cardiovascular (CV) outcomes in the general population as well as in patients with cardiovascular disease (CVD). Statins' beneficial effects have been attributed to both cholesterol-lowering and cholesterol-independent "pleiotropic" properties. By their pleiotropic effects statins have been shown to reduce inflammation, alleviate oxidative stress, modify the immunologic responses, improve endothelial function and suppress platelet aggregation. Patients with chronic kidney disease (CKD) exhibit an enormous increase in CVD rates even from early CKD stages. As considerable differences exist in dyslipidemia characteristics and the pathogenesis of CVD in CKD, statins' CV benefits in CKD patients (including those with a kidney graft) should not be considered unequivocal. Indeed, accumulating clinical evidence suggests that statins exert diverse effects on dialysis and non-dialysis CKD patients. Therefore, it seems that statins improve CV outcomes in non-dialysis patients whereas exert little (if any) benefit in the dialysis population. It has also been proposed that dyslipidemia might play a causative role or even accelerate renal injury. Moreover, ample experimental evidence suggests that statins ameliorate renal damage. However, a high quality randomized controlled trial (RCT) and metaanalyses do not support a beneficial role of statins in renal outcomes in terms of proteinuria reduction or retardation of glomerular filtration rate (GFR) decline.

Statins stabilize the renal function of IgA nephropathy

BACKGROUND

The renoprotective pleiotropic effect of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) has recently been reported by several investigators. However, the effect of statins on IgA nephropathy (IgAN) is still unknown.

METHODS

We selected 24 IgAN patients who had newly started statin therapy and were not treated with steroids and immunosuppressive agents during the observation period. We analyzed and compared clinical findings 1 year before and after treatment.

RESULTS

Mean age was 50.5 ± 9.91 years and mean blood pressure was 90.9 ± 10.8 mmHg. Renal function was slightly deteriorated, serum creatinine was 1.03 (0.71-1.24) mg/dL and estimated glomerular filtration rate (eGFR) was 55.8 ± 22.8 mL/min. Lipid metabolism was poorly controlled [total cholesterol 247.7 ± 35.7 mg/dL, low-density lipoprotein cholesterol 151.5 (140.8-172.8) mg/dL, and triglyceride 163.0 (126.3-243.8) mg/dL]. Mild urinary abnormality was observed [proteinuria: 0.50 (0.22-1.29) g/g creatinine, urinary red blood cells 1.0 (0.2-5.0) per high power field]. After 1 year of statin treatment, lipid control was significantly better than at baseline. Proteinuria was not significantly decreased but renal function was improved. eGFR changed from a -5.9% decrease to a 2.4% increase (p = 0.0098).

CONCLUSION

Our results indicated that statins stabilized the renal function of IgAN patients independent of their reduction of proteinuria.

Management of atrial fibrillation in chronic kidney disease: double trouble

Chronic kidney disease (CKD) has a very well-established link with cardiovascular disease. Below stage 3 CKD (glomerular filtration rate <60 mL/min), there is a progressive increase in both total mortality and cardiovascular-specific mortality as kidney function declines; indeed, it is more likely for a patient with CKD stage 3 to die of cardiovascular disease than to progress to CKD stage 4 and beyond. Arrhythmia is particularly common in patients with CKD. Depending on the study and measurement used, the prevalence of patients with CKD with chronic atrial fibrillation (AF) is quoted at 7% to 18%, rising to 12% to 25% for those older than 70 years. These rates are up to 2 to 3 times higher than in the general population. Of all patients with AF, 10% to 15% will have CKD. However, not all standard rate and rhythm methods are suitable for this population and those that are tend to be less effective. Meanwhile, anticoagulation has long been a thorny subject, with much conflicting evidence around the balance between bleeding and stroke risk. To help clarify this, we first highlight the challenges of performing evidence-based medicine in the patient with renal disease, and then review recent and emerging research to suggest an approach to the management of patients with renal disease who have AF. We also review the potential role of the different new oral anticoagulant drugs in CKD.

End-stage renal disease and limb salvage

The prevalence of peripheral arterial disease and both traditional and nontraditional vascular risk factors are more common in patients with end-stage renal disease who are undergoing hemodialysis than the general population. Patients undergoing hemodialysis may also be at risk for peripheral arterial disease via nonvascular risk factors and the hemodialysis treatment itself. Unfortunately, because peripheral arterial disease and its risk factors in hemodialysis patients have not been thoroughly ascertained, evaluation of potential treatments has been limited. Given the high potential of morbidity and impaired quality-of-life related to peripheral arterial disease in patients with end-stage renal disease, additional studies are needed to evaluate both quality of life and potential screening for peripheral arterial disease, its risk factors, and treatments to identify areas for improvement in this vulnerable population.