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Cashmore B, Tunnicliffe DJ, Palmer S, Blythen L, Boag J, Kostner K, Krishnasamy R, Lambert K, Miller A, Mullan J, Patu M, Phoon RKS, Rix L, Trompf N, Johnson DW, Walker R. Australian and New Zealand Living Guideline cholesterol-lowering therapy for people with chronic kidney disease (CARI Guidelines): Reducing the evidence-practice gap. Nephrology (Carlton) 2024; 29:495-509. [PMID: 38684481 DOI: 10.1111/nep.14295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 02/23/2024] [Accepted: 03/10/2024] [Indexed: 05/02/2024]
Abstract
AIM People with chronic kidney disease experience high rates of cardiovascular disease. Cholesterol-lowering therapy is a mainstay in the management but there is uncertainty in the treatment effects on patient-important outcomes, such as fatigue and rhabdomyolysis. Here, we summarise the updated CARI Australian and New Zealand Living Guidelines on cholesterol-lowering therapy in chronic kidney disease. METHODS We updated a Cochrane review and monitored newly published studies weekly to inform guideline development according to international standards. The Working Group included expertise from nephrology, cardiology, Indigenous Health, guideline development and people with lived experience of chronic kidney disease. RESULTS The guideline recommends people with chronic kidney disease (eGFR ≥15 mL/min/1.73 m2) and an absolute cardiovascular risk of 10% or higher should receive statin therapy (with or without ezetimibe) to reduce the risk of cardiovascular events and death (strong recommendation, moderate certainty evidence). The guidelines also recommends a lower absolute cardiovascular risk threshold (≥5%) for Aboriginal and Torres Strait Islander Peoples and Māori with chronic kidney disease to receive statin therapy (with or without ezetimibe) (strong recommendation, low certainty evidence). The evidence was actively surveyed from 2020-2023 and updated as required. No changes to guideline recommendations were made, with no new data on the balance and benefits of harms. CONCLUSIONS The development of living guidelines was feasible and provided the opportunity to update recommendations to improve clinical decision-making in real-time. Living guidelines provide the opportunity to transform chronic kidney disease guidelines.
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Affiliation(s)
- Brydee Cashmore
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children's Hospital of Westmead, Sydney, New South Wales, Australia
| | - David J Tunnicliffe
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children's Hospital of Westmead, Sydney, New South Wales, Australia
| | - Suetonia Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | | | - Jane Boag
- Consumer Partner, Australia
- School of Health, Federation University, Ballarat, Victoria, Australia
| | - Karam Kostner
- Mater Hospital, University of Queensland, St Lucia, Queensland, Australia
| | - Rathika Krishnasamy
- Department of Nephrology, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
- Centre for Kidney Disease Research, The University of Queensland, Brisbane, Queensland, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Queensland, Australia
| | - Kelly Lambert
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Andrea Miller
- Cape York Kidney Care, Weipa Integrated Health Services, Weipa, Queensland, Australia
| | - Judy Mullan
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Maira Patu
- Māori/Indigenous Health Institute, University of Otago, Christchurch, New Zealand
| | - Richard K S Phoon
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Renal Medicine, Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia
| | - Liz Rix
- Adelaide Nursing School, University of Adelaide, Adelaide, South Australia, Australia
| | | | - David W Johnson
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Queensland, Australia
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- Translational Research Institute, Brisbane, Queensland, Australia
| | - Robert Walker
- Department of Medicine, University of Otago Dunedin, Dunedin, New Zealand
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Mathew RO, Sidhu MS, Rihal CS, Lennon R, El-Hajjar M, Yager N, Lyubarova R, Abdul-Nour K, Weitz S, O'Cochlain DF, Murthy V, Levisay J, Marzo K, Graham J, Dzavik V, So D, Goodman S, Rosenberg YD, Pereira N, Farkouh ME. Safety and Efficacy of CYP2C19 Genotype-Guided Escalation of P2Y 12 Inhibitor Therapy After Percutaneous Coronary Intervention in Chronic Kidney Disease: a Post Hoc Analysis of the TAILOR-PCI Study. Cardiovasc Drugs Ther 2024; 38:447-457. [PMID: 36445624 PMCID: PMC10225474 DOI: 10.1007/s10557-022-07392-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Chronic kidney disease (CKD) is a risk factor for ischemic and bleeding events with dual antiplatelet therapy after percutaneous coronary intervention (PCI). Whether the presence of CYP2C19 loss of function (LOF) alleles modifies this risk, and whether a genotype-guided (GG) escalation of P2Y12 inhibitor therapy post PCI is safe in this population is unclear. METHODS This was a post hoc analysis of randomized patients in TAILOR PCI. Patients were divided into two groups based on estimated glomerular filtration rate (eGFR) threshold of < 60 ml/min/1.73 m2 for CKD (n = 539) and non-CKD (n = 4276). The aggregate of cardiovascular death, stroke, myocardial infarction, stent thrombosis, and severe recurrent coronary ischemia at 12-months post-PCI was assessed as the primary endpoint. Secondary endpoint was major or minor bleeding. RESULTS Mean (standard deviation) eGFR among patients with CKD was 49.5 (8.4) ml/min/1.72 m2. Among all patients, there was no significant interaction between randomized strategy and CKD status for any endpoint. Among LOF carriers, the interaction between randomized strategy and CKD status on composite ischemic outcome was not significant (p = 0.2). GG strategy was not associated with an increased risk of bleeding in either CKD group. CONCLUSIONS In this exploratory analysis, escalation of P2Y12 inhibitor therapy following a GG strategy did not reduce the primary outcome in CKD. However, P2Y12 inhibitor escalation following a GG strategy was not associated with increased bleeding risk in CKD. Larger studies in CKD are needed. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov/ct2/show/NCT01742117?term=TAILOR-PCI&draw=2&rank=1 . NCT01742117.
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Affiliation(s)
- Roy O Mathew
- Department of Medicine, Loma Linda VA Health Care System, 11201 Benton Street, Loma Linda, CA, 92357, USA.
| | - Mandeep S Sidhu
- Department of Medicine, Albany Medical College, 43 New Scotland Avenue Albany, Schenectady, NY, 12208, USA.
| | | | - Ryan Lennon
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Mohammed El-Hajjar
- Department of Medicine, Albany Medical College, 43 New Scotland Avenue Albany, Schenectady, NY, 12208, USA
| | - Neil Yager
- Department of Medicine, Albany Medical College, 43 New Scotland Avenue Albany, Schenectady, NY, 12208, USA
| | - Radmila Lyubarova
- Department of Medicine, Albany Medical College, 43 New Scotland Avenue Albany, Schenectady, NY, 12208, USA
| | | | - Steven Weitz
- Cardiology Associates of Schenectady, Schenectady, NY, USA
| | | | - Vishakantha Murthy
- Department of Endocrine and Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Justin Levisay
- Department of Medicine, North Shore University Health System, Evanston, IL, USA
| | - Kevin Marzo
- Department of Medicine, Winthrop University Hospital, Mineola, NY, USA
| | - John Graham
- Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | - Vlad Dzavik
- Department of Medicine, University Health Network-Toronto General Hospital, Toronto, ON, Canada
| | - Derek So
- Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Shaun Goodman
- Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | | | | | - Michael E Farkouh
- Department of Medicine, University Health Network-Toronto General Hospital, Toronto, ON, Canada
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Kratky V, Valerianova A, Hruskova Z, Tesar V, Malik J. Increased Cardiovascular Risk in Young Patients with CKD and the Role of Lipid-Lowering Therapy. Curr Atheroscler Rep 2024; 26:103-109. [PMID: 38289577 DOI: 10.1007/s11883-024-01191-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE OF REVIEW Chronic kidney disease (CKD) is associated with a significantly increased risk of cardiovascular disease (CVD). This review summarizes known risk factors, pathophysiological mechanisms, and current therapeutic possibilities, focusing on lipid-lowering therapy in CKD. RECENT FINDINGS Novel data on lipid-lowering therapy in CKD mainly stem from clinical trials and clinical studies. In addition to traditional CVD risk factors, patients with CKD often present with non-traditional risk factors that include, e.g., anemia, proteinuria, or calcium-phosphate imbalance. Dyslipidemia remains an important contributing CVD risk factor in CKD, although the mechanisms involved differ from the general population. While statins are the most commonly used lipid-lowering therapy in CKD patients, some statins may require dose reduction. Importantly, statins showed diminished beneficial effect on cardiovascular events in patients with severe CKD and hypercholesterolemia despite high CVD risk and effective reduction of LDL cholesterol. Ezetimibe enables the reduction of the dose of statins and their putative toxicity and, in combination with statins, reduces CVD endpoints in CKD patients. The use of novel drugs such as PCSK9 inhibitors is safe in CKD, but their potential to reduce cardiovascular events in CKD needs to be elucidated in future studies.
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Affiliation(s)
- Vojtech Kratky
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Anna Valerianova
- 3rd Department of Internal Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 499/2, 128 08, Prague, Czech Republic
| | - Zdenka Hruskova
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.
| | - Vladimir Tesar
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Jan Malik
- 3rd Department of Internal Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 499/2, 128 08, Prague, Czech Republic
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Tunnicliffe DJ, Palmer SC, Cashmore BA, Saglimbene VM, Krishnasamy R, Lambert K, Johnson DW, Craig JC, Strippoli GF. HMG CoA reductase inhibitors (statins) for people with chronic kidney disease not requiring dialysis. Cochrane Database Syst Rev 2023; 11:CD007784. [PMID: 38018702 PMCID: PMC10685396 DOI: 10.1002/14651858.cd007784.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
BACKGROUND Cardiovascular disease is the most frequent cause of death in people with early stages of chronic kidney disease (CKD), and the absolute risk of cardiovascular events is similar to people with coronary artery disease. This is an update of a review first published in 2009 and updated in 2014, which included 50 studies (45,285 participants). OBJECTIVES To evaluate the benefits and harms of statins compared with placebo, no treatment, standard care or another statin in adults with CKD not requiring dialysis. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 4 October 2023. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. An updated search will be undertaken every three months. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs that compared the effects of statins with placebo, no treatment, standard care, or other statins, on death, cardiovascular events, kidney function, toxicity, and lipid levels in adults with CKD (estimated glomerular filtration rate (eGFR) 90 to 15 mL/min/1.73 m2) were included. DATA COLLECTION AND ANALYSIS Two or more authors independently extracted data and assessed the study risk of bias. Treatment effects were expressed as mean difference (MD) for continuous outcomes and risk ratios (RR) for dichotomous benefits and harms with 95% confidence intervals (CI). The risk of bias was assessed using the Cochrane risk of bias tool, and the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS We included 63 studies (50,725 randomised participants); of these, 53 studies (42,752 participants) compared statins with placebo or no treatment. The median duration of follow-up was 12 months (range 2 to 64.8 months), the median dosage of statin was equivalent to 20 mg/day of simvastatin, and participants had a median eGFR of 55 mL/min/1.73 m2. Ten studies (7973 participants) compared two different statin regimens. We were able to meta-analyse 43 studies (41,273 participants). Most studies had limited reporting and hence exhibited unclear risk of bias in most domains. Compared with placebo or standard of care, statins prevent major cardiovascular events (14 studies, 36,156 participants: RR 0.72, 95% CI 0.66 to 0.79; I2 = 39%; high certainty evidence), death (13 studies, 34,978 participants: RR 0.83, 95% CI 0.73 to 0.96; I² = 53%; high certainty evidence), cardiovascular death (8 studies, 19,112 participants: RR 0.77, 95% CI 0.69 to 0.87; I² = 0%; high certainty evidence) and myocardial infarction (10 studies, 9475 participants: RR 0.55, 95% CI 0.42 to 0.73; I² = 0%; moderate certainty evidence). There were too few events to determine if statins made a difference in hospitalisation due to heart failure. Statins probably make little or no difference to stroke (7 studies, 9115 participants: RR 0.64, 95% CI 0.37 to 1.08; I² = 39%; moderate certainty evidence) and kidney failure (3 studies, 6704 participants: RR 0.98, 95% CI 0.91 to 1.05; I² = 0%; moderate certainty evidence) in people with CKD not requiring dialysis. Potential harms from statins were limited by a lack of systematic reporting. Statins compared to placebo may have little or no effect on elevated liver enzymes (7 studies, 7991 participants: RR 0.76, 95% CI 0.39 to 1.50; I² = 0%; low certainty evidence), withdrawal due to adverse events (13 studies, 4219 participants: RR 1.16, 95% CI 0.84 to 1.60; I² = 37%; low certainty evidence), and cancer (2 studies, 5581 participants: RR 1.03, 95% CI 0.82 to 1.30; I² = 0%; low certainty evidence). However, few studies reported rhabdomyolysis or elevated creatinine kinase; hence, we are unable to determine the effect due to very low certainty evidence. Statins reduce the risk of death, major cardiovascular events, and myocardial infarction in people with CKD who did not have cardiovascular disease at baseline (primary prevention). There was insufficient data to determine the benefits and harms of the type of statin therapy. AUTHORS' CONCLUSIONS Statins reduce death and major cardiovascular events by about 20% and probably make no difference to stroke or kidney failure in people with CKD not requiring dialysis. However, due to limited reporting, the effect of statins on elevated creatinine kinase or rhabdomyolysis is unclear. Statins have an important role in the primary prevention of cardiovascular events and death in people who have CKD and do not require dialysis. Editorial note: This is a living systematic review. We will search for new evidence every three months and update the review when we identify relevant new evidence. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- David J Tunnicliffe
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Brydee A Cashmore
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Valeria M Saglimbene
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | | | - Kelly Lambert
- School of Medicine, University of Wollongong, Wollongong, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Giovanni Fm Strippoli
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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He Z, Lin Y, Dong S, Ke Q, Zheng S, Ling Q. Development and validation of a nomogram model for predicting chronic kidney disease after liver transplantation: a multi-center retrospective study. Sci Rep 2023; 13:11380. [PMID: 37452094 PMCID: PMC10349045 DOI: 10.1038/s41598-023-38626-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/11/2023] [Indexed: 07/18/2023] Open
Abstract
Chronic kidney disease (CKD) is a frequent complication after liver transplantation (LT) and associated with poor prognosis. In this study, we retrospectively analyzed 515 adult patients who underwent LT in our center. They were randomly divided into a training set (n = 360) and an internal test set (n = 155). Another 118 recipients in other centers served as external validation set. Univariate and multivariate COX regression analysis were used to determine risk factors. A nomogram model was developed to predict post-LT CKD. The incidence of post-LT CKD in our center was 16.9% (87/515) during a median follow-up time of 22.73 months. The overall survival of recipients with severe CKD (stage IV and V) were significantly lower than those with non or mild CKD (stage III) (p = 0.0015). A nomogram model was established based on recipient's age, anhepatic phase, estimated glomerular filtration rate and triglyceride levels at 30 days after LT. The calibration curves for post-LT CKD prediction in the nomogram were consistent with the actual observation in both the internal and external validation set. In conclusion, severe post-LT CKD resulted in a significantly reduced survival in liver recipient. The newly established nomogram model had good predictive ability for post-LT CKD.
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Affiliation(s)
- Zenglei He
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Yimou Lin
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Siyi Dong
- China Liver Transplant Registry, Hangzhou, 310003, China
| | - Qinghong Ke
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Shusen Zheng
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Qi Ling
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China.
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Lee M, Hong YA, Myong JP, Lee K, Park MW, Kim DW. Trends and outcome of statin therapy in dialysis patients with atherosclerotic cardiovascular diseases: A population-based cohort study. PLoS One 2023; 18:e0286670. [PMID: 37267287 DOI: 10.1371/journal.pone.0286670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 05/22/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Although statins are an effective strategy for the secondary prevention of atherosclerotic cardiovascular disease (ASCVD) in the general population, the benefits for dialysis patients are controversial. We sought to assess trends of statin use and evaluate outcomes of statin therapy in dialysis patients with different types of ASCVD. METHODS This nationwide retrospective population-based cohort study using data from the Korean National Health Insurance Service included adult patients (aged ≥ 18 years) undergoing chronic dialysis who had an initial ASCVD event in the time period of 2013 to 2018. Annual trends of statin use according to age, sex, and ASCVD types were analyzed. The association between 1-year mortality and statin use was examined using multivariable Cox proportional hazards regression analyses. RESULTS Among 17,242 subjects, 9,611(55.7%) patients were statin users. The overall prevalence of statin use increased from 52.9% in 2013 to 57.7% in 2018; the majority (77%) of dialysis patients were prescribed moderate-intensity statins. The proportions of low- or moderate-intensity statin use were similar, but high-intensity statin use increased from 5.7% in 2013 to 10.5% in 2018. The use of the statin/ezetimibe combination has gradually increased since 2016. Statin use was independently associated with the reduced 1-year all-cause mortality after adjusting for confounding factors (hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.80-0.96, P = 0.004). CONCLUSION The prevalence of statin prescriptions in dialysis patients after ASCVD event increased from 2013 to 2018. Most patients received moderate-intensity statin. However, high-intensity statin and statin/ezetimibe combination therapy has remarkably increased. Statin use was associated with decreased 1-year all-cause mortality in dialysis patients with ASCVD.
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Affiliation(s)
- Myunhee Lee
- Division of Cardiology, Department of Internal Medicine, Daejeon St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
- Catholic Research Institute for Intractable Cardiovascular Disease CRID, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yu Ah Hong
- Division of Nephrology, Department of Internal Medicine, Daejeon St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Jun-Pyo Myong
- Department of Occupational and Environmental Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Kyusup Lee
- Division of Cardiology, Department of Internal Medicine, Daejeon St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
- Catholic Research Institute for Intractable Cardiovascular Disease CRID, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Mahn-Won Park
- Division of Cardiology, Department of Internal Medicine, Daejeon St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
- Catholic Research Institute for Intractable Cardiovascular Disease CRID, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dae-Won Kim
- Division of Cardiology, Department of Internal Medicine, Daejeon St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
- Catholic Research Institute for Intractable Cardiovascular Disease CRID, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Oliver W, Giugliano RP. Benefit of Combination Ezetimibe/Simvastatin Among High-Risk Populations: Lessons from the IMPROVE-IT Trial. Curr Atheroscler Rep 2023; 25:85-93. [PMID: 36763180 DOI: 10.1007/s11883-023-01084-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2023] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW The Improved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) demonstrated the clinical benefit of the combination of ezetimibe-simvastatin compared to placebo-simvastatin following acute coronary syndrome (ACS). This review highlights key findings from this study with particular attention to the practice-changing impact on guidelines for low-density lipoprotein cholesterol (LDL-C) reduction after ACS, especially among high-risk populations. RECENT FINDINGS Consistent reductions in LDL-C have been reported with newer lipid-lowering therapies (proprotein convertase subtilisin/kexin type 9 inhibitors, cholesterol ester transfer proteins, bempedoic acid) in combination with statin in high-risk subgroups. Since high-risk subgroups remain a focus of guidelines, exploration of high-risk subgroups can help define the optimal use of new therapies. Ezetimibe reduced the LDL-C by 16.7 mg/dL compared to placebo at 1 year, resulting in a significant reduction in the primary composite endpoint (absolute risk difference 2.0%; relative risk difference 6.4%, hazard ratio, 0.936; 95% confidence interval, 0.89 to 0.99; P = 0.016). The benefits achieved with ezetimibe in both LDL-C reduction and the primary clinical composite across 10 pre-specified high-risk subgroups, including the elderly; women; patients with diabetes, prior coronary artery bypass graft, history of stroke, polyvascular disease, low baseline LDL-C, renal dysfunction, prior heart failure, and an elevated TIMI risk score for secondary prevention, were similar or greater than in the corresponding non-high-risk subgroups. Safety events were similar between ezetimibe and placebo across the high-risk subgroups. These data support the addition of ezetimibe to statin therapy in high-risk patients who require additional therapy to lower the LDL-C post-ACS.
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Affiliation(s)
- Walter Oliver
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Robert P Giugliano
- Cardiovascular Medicine Division, Brigham and Women's Hospital, TIMI Study Office, Hale BTM, Suite 7022, 60 Fenwood Road, Boston, MA, 02115, USA.
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8
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Choudhary A, Rawat U, Kumar P, Mittal P. Pleotropic effects of statins: the dilemma of wider utilization of statin. Egypt Heart J 2023; 75:1. [PMID: 36602642 PMCID: PMC9816367 DOI: 10.1186/s43044-023-00327-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/30/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Apart from reducing the circulating LDL-c and the number of cardiovascular cases as well as fatalities, statins have auxiliary non-lipid-related or cholesterol independent effects, the pleiotropic effects. The aim of the present review is to understand the pleotropic effects of statins. MAIN BODY Cardiovascular disease (CVD) is presently the major cause of patient misery as well as mortality among non-communicable diseases (NCDs) in the world. Despite the fact that statins are the most extensively affirmed, prescribed and evidence-based lipid-lowering medicine worldwide that curtail low density lipoprotein cholesterol (LDL-c) levels and the number of cardiovascular cases as well as deaths, statins also elicit auxiliary non-lipid-related or cholesterol independent effects, the pleiotropic effects. Improved endothelial function, significantly lowered oxidative stress, atherosclerotic plaque stabilization, immunomodulatory, cessation of vascular smooth muscle proliferation, effects on bone metabolism, anti-inflammatory, antithrombotic effects, and reduced risk of dementia are among these pleotropic effects. Statins have also been explored for its uses in life threatening diseases like cancer and inflammatory bowel disease. They have been demonstrated to revamp vascular tone. Many research and review articles have been thoroughly studied for this systematic review. CONCLUSIONS Statins have not only shown to be benefitial in lowering the levels of LDL-C but have also been established to be advantageous in the treatment of cancer, neurological conditions like dementia, multiple sclerosis, inflammatory bowel disease. Future high-quality trials are needed to include statins in the treatment of these conditions as per guidelines.
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Affiliation(s)
- Ambika Choudhary
- grid.449731.c0000 0004 4670 6826Teerthanker Mahaveer College of Pharmacy, Teerthanker Mahaveer University, Moradabad, India
| | - Ujjawal Rawat
- grid.449731.c0000 0004 4670 6826Teerthanker Mahaveer College of Pharmacy, Teerthanker Mahaveer University, Moradabad, India
| | - Piyush Kumar
- grid.449731.c0000 0004 4670 6826Teerthanker Mahaveer College of Pharmacy, Teerthanker Mahaveer University, Moradabad, India
| | - Piyush Mittal
- grid.449731.c0000 0004 4670 6826Teerthanker Mahaveer College of Pharmacy, Teerthanker Mahaveer University, Moradabad, India
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Liao G, Wang X, Li Y, Chen X, Huang K, Bai L, Ye Y, Peng Y. Antidyslipidemia Pharmacotherapy in Chronic Kidney Disease: A Systematic Review and Bayesian Network Meta-Analysis. Pharmaceutics 2022; 15:pharmaceutics15010006. [PMID: 36678635 PMCID: PMC9862001 DOI: 10.3390/pharmaceutics15010006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/30/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND AIMS The benefits and safety of antidyslipidemia pharmacotherapy in patients with chronic kidney disease were not well defined so the latest evidence was summarized by this work. METHODS This systematic review and Bayesian network meta-analysis (NMA) included searches of PubMed, Embase, and Cochrane Library from inception to 28 February 2022, for randomized controlled trials of any antilipidaemic medications administered to adults with chronic kidney disease [CKD: defined as estimated glomerular filtration rate (eGFR) ≤ 60 mL/min/1.73 m2 not undergoing transplantation], using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool to assess the certainty of the evidence. RESULTS 55 trials and 30 works of them were included in our systematic review and NMA, respectively. In comparisons with no antidyslipidemia therapy or placebo, proprotein convertase subtilisin/Kexin type 9 inhibitors plus statin (PS) was the most effective drug regimen for reducing all-cause mortality (OR 0.62, 95% CI [0.40, 0.93]; GRADE: moderate), followed by moderate-high intensity statin (HS, OR 0.76, 95% CI [0.60, 0.93]; I2 = 66.9%; GRADE: moderate). PS, HS, low-moderate statin (LS), ezetimibe plus statin (ES), and fibrates (F) significantly decreased the composite cardiovascular events. The subgroup analysis revealed the null effect of statins on death (OR 0.92, 95% CI [0.81, 1.04]) and composite cardiovascular events (OR 0.94, 95% CI [0.82, 1.07]) in dialysis patients. CONCLUSION In nondialysis CKD patients, statin-based therapies could significantly and safely reduce all-cause death and major composite cardiovascular events despite the presence of arteriosclerotic cardiovascular disease and LDL-c levels. Aggressive medication regimens, PS and HS, appeared to be more effective, especially in patients with established CAD.
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Affiliation(s)
- Guangzhi Liao
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu 610041, China
| | - Xiangpeng Wang
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yiming Li
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu 610041, China
| | - Xuefeng Chen
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu 610041, China
| | - Ke Huang
- West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Lin Bai
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu 610041, China
| | - Yuyang Ye
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu 610041, China
| | - Yong Peng
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu 610041, China
- Correspondence: ; Tel.: +86-28-85423362; Fax: +86-28-85423169
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10
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Warrens H, Banerjee D, Herzog CA. Cardiovascular Complications of Chronic Kidney Disease: An Introduction. Eur Cardiol 2022; 17:e13. [PMID: 35620357 PMCID: PMC9127633 DOI: 10.15420/ecr.2021.54] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 11/22/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Hilary Warrens
- St George’s University of London, St George’s NHS Foundation Trust, London, UK
| | - Debasish Banerjee
- St George’s University of London, St George’s NHS Foundation Trust, London, UK
| | - Charles A Herzog
- Division of Cardiology, Department of Internal Medicine, Hennepin Healthcare, Minneapolis, MN, US; Department of Medicine, University of Minnesota, Minneapolis, MN, US
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11
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Pan X. Cholesterol Metabolism in Chronic Kidney Disease: Physiology, Pathologic Mechanisms, and Treatment. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1372:119-143. [PMID: 35503178 PMCID: PMC11106795 DOI: 10.1007/978-981-19-0394-6_9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
High plasma levels of lipids and/or lipoproteins are risk factors for atherosclerosis, nonalcoholic fatty liver disease (NAFLD), obesity, and diabetes. These four conditions have also been identified as risk factors leading to the development of chronic kidney disease (CKD). Although many pathways that generate high plasma levels of these factors have been identified, most clinical and physiologic dysfunction results from aberrant assembly and secretion of lipoproteins. The results of several published studies suggest that elevated levels of low-density lipoprotein (LDL)-cholesterol are a risk factor for atherosclerosis, myocardial infarction, coronary artery calcification associated with type 2 diabetes, and NAFLD. Cholesterol metabolism has also been identified as an important pathway contributing to the development of CKD; clinical treatments designed to alter various steps of the cholesterol synthesis and metabolism pathway are currently under study. Cholesterol synthesis and catabolism contribute to a multistep process with pathways that are regulated at the cellular level in renal tissue. Cholesterol metabolism may also be regulated by the balance between the influx and efflux of cholesterol molecules that are capable of crossing the membrane of renal proximal tubular epithelial cells and podocytes. Cellular accumulation of cholesterol can result in lipotoxicity and ultimately kidney dysfunction and failure. Thus, further research focused on cholesterol metabolism pathways will be necessary to improve our understanding of the impact of cholesterol restriction, which is currently a primary intervention recommended for patients with dyslipidemia.
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Affiliation(s)
- Xiaoyue Pan
- Department of Foundations of Medicine, New York University Long Island School of Medicine, Mineola, NY, USA.
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12
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Poudel B, Rosenson RS, Bittner V, Gutiérrez OM, Anderson AH, Woodward M, Deo R, Carson AP, Mues KE, Dluzniewski PJ, Jaar BG, Lora CM, Taliercio J, Muntner P, Colantonio LD. Atherosclerotic Cardiovascular Disease Events in Adults With CKD Taking a Moderate- or High-Intensity Statin: The Chronic Renal Insufficiency Cohort (CRIC) Study. Kidney Med 2021; 3:722-731.e1. [PMID: 34693254 PMCID: PMC8515092 DOI: 10.1016/j.xkme.2021.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Rationale & Objective The 2018 American Heart Association/American College of Cardiology (AHA/ACC) cholesterol guideline uses risk stratification to guide the decision to initiate nonstatin lipid-lowering medication among adults with atherosclerotic cardiovascular disease (CVD). We determined atherosclerotic CVD (ASCVD) event rates among adults with chronic kidney disease (CKD) taking statin therapy within 2018 AHA/ACC cholesterol guideline risk categories. Study Design Observational cohort study. Setting & Participants Adults with CKD not on dialysis in the Chronic Renal Insufficiency Cohort (CRIC) study who were taking a moderate/high-intensity statin 1 year after enrollment (baseline for the current analysis, n = 1,753). Exposure 2018 AHA/ACC cholesterol guideline risk categories: without a history of ASCVD, a history of 1 major ASCVD event and multiple high-risk conditions, and a history of ≥2 major ASCVD events. Outcome Adjudicated ASCVD events after the year 1 study visit. Analytical Approach We calculated age-sex standardized rates for ASCVD events and age-sex adjusted hazard ratios for ASCVD events accounting for the competing risk of death. Results There were 394 ASCVD events over a median follow-up period of 8 years. The ASCVD event rates (with 95% CI) per 1,000 person-years among participants without a history of ASCVD, with a history of 1 major ASCVD event and multiple high-risk conditions, and with a history of ≥2 major ASCVD events were 21.7 (18.4-25.1), 45.0 (37.8-52.3), and 73.3 (53.3-93.4), respectively. Compared with participants without a history of ASCVD, the HR (95% CI) rates for ASCVD events among those with a history of 1 major ASCVD event and multiple high-risk conditions, and with a history of ≥2 major ASCVD events were 1.89 (1.52-2.36) and 2.50 (1.85-3.39), respectively. Limitations Data on whether participants were taking a maximally tolerated statin dosage were unavailable. Conclusions The 2018 AHA/ACC cholesterol guideline identifies adults with CKD who have very high ASCVD risk despite taking a moderate/high-intensity statin.
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Affiliation(s)
- Bharat Poudel
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | - Robert S Rosenson
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Vera Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Orlando M Gutiérrez
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL.,Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Mark Woodward
- George Institute for Global Health, Imperial College London, United Kingdom.,George Institute for Global Health, University of New South Wales, Sydney, Australia.,Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore MD
| | - Rajat Deo
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - April P Carson
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | - Katherine E Mues
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA
| | | | - Bernard G Jaar
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore MD.,Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore MD
| | - Claudia M Lora
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Jonathan Taliercio
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, OH
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
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13
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Fras Z, Mikhailidis DP. Have We Learnt all from IMPROVE-IT? Part I. Core Results and Subanalyses on the Effects of Ezetimibe Added to Statin Therapy Related to Age, Gender and Selected Chronic Diseases (Kidney Disease, Diabetes Mellitus and Non-Alcoholic Fatty Liver Disease). Curr Vasc Pharmacol 2021; 19:451-468. [DOI: 10.2174/1570161118999200727224946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 06/23/2020] [Accepted: 07/03/2020] [Indexed: 11/22/2022]
Abstract
IMPROVE-IT (IMProved Reduction of Outcomes: Vytorin Efficacy International Trial) was
a randomized clinical trial (including 18,144 patients) that evaluated the efficacy of the combination of
ezetimibe with simvastatin vs. simvastatin monotherapy in patients with acute coronary syndrome
(ACS) and moderately increased low-density lipoprotein cholesterol (LDL-C) levels (of up to 2.6-3.2
mmol/L; 100-120 mg/dL). After 7 years of follow-up, combination therapy resulted in an additional
LDL-C decrease [to 1.8 mmol/L, or 70 mg/dL, within the simvastatin (40 mg/day) monotherapy arm
and to 1.4 mmol/L, or 53 mg/dL for simvastatin (40 mg/day) + ezetimibe (10 mg/day)] and showed an
incremental clinical benefit [composite of cardiovascular death, nonfatal myocardial infarction, unstable
angina requiring rehospitalization, coronary revascularization (≥30 days after randomization), or nonfatal
stroke; hazard ratio (HR) of 0.936, and 95% CI 0.887-0.996, p=0.016]. Therefore, for very high cardiovascular
risk patients “even lower is even better” regarding LDL-C, independently of the LDL-C
reducing strategy. These findings confirm ezetimibe as an option to treat very-high-risk patients who
cannot achieve LDL-C targets with statin monotherapy. Additional analyses of the IMPROVE-IT (both
prespecified and post-hoc) include specific very-high-risk subgroups of patients (those with previous
acute events and/or coronary revascularization, older than 75 years, as well as patients with diabetes
mellitus, chronic kidney disease or non-alcoholic fatty liver disease). The data from IMPROVE-IT also
provide reassurance regarding longer-term safety and efficacy of the intensification of lipid-lowering
therapy in very-high-risk patients resulting in very low LDL-C levels. We comment on the results of
several (sub) analyses of IMPROVE-IT.
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Affiliation(s)
- Zlatko Fras
- Centre for Preventive Cardiology, Department of Vascular Medicine, Division of Medicine, University Medical Centre, Ljubljana, Slovenia
| | - Dimitri P. Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College Medical School, University College London, London, United Kingdom
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14
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Use of Lipid-Modifying Agents for the Treatment of Glomerular Diseases. J Pers Med 2021; 11:jpm11080820. [PMID: 34442464 PMCID: PMC8401447 DOI: 10.3390/jpm11080820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 08/17/2021] [Indexed: 01/14/2023] Open
Abstract
Although dyslipidemia is associated with chronic kidney disease (CKD), it is more common in nephrotic syndrome (NS), and guidelines for the management of hyperlipidemia in NS are largely opinion-based. In addition to the role of circulating lipids, an increasing number of studies suggest that intrarenal lipids contribute to the progression of glomerular diseases, indicating that proteinuric kidney diseases may be a form of "fatty kidney disease" and that reducing intracellular lipids could represent a new therapeutic approach to slow the progression of CKD. In this review, we summarize recent progress made in the utilization of lipid-modifying agents to lower renal parenchymal lipid accumulation and to prevent or reduce kidney injury. The agents mentioned in this review are categorized according to their specific targets, but they may also regulate other lipid-relevant pathways.
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15
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Mathew RO, Rosenson RS, Lyubarova R, Chaudhry R, Costa SP, Bangalore S, Sidhu MS. Concepts and Controversies: Lipid Management in Patients with Chronic Kidney Disease. Cardiovasc Drugs Ther 2021; 35:479-489. [PMID: 32556851 DOI: 10.1007/s10557-020-07020-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) remains an important contributor of morbidity and mortality in patients with chronic kidney disease (CKD). CKD is recognized as an important risk enhancer that identifies patients as candidates for more intensive low-density lipoprotein (LDL) cholesterol lowering. However, there is controversy regarding the efficacy of lipid-lowering therapy, especially in patients on dialysis. Among patients with CKD, not yet on dialysis, there is clinical trial evidence for the use of statins with or without ezetimibe to reduce ASCVD events. Newer cholesterol lowering agents have been introduced for the management of hyperlipidemia to reduce ASCVD, but these therapies have not been tested in the CKD population except in secondary analyses of patients with primarily CKD stage 3. This review summarizes the role of hyperlipidemia in ASCVD and treatment strategies for hyperlipidemia in the CKD population.
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Affiliation(s)
- Roy O Mathew
- Columbia V.A. Health Care System, 6439 Garners Ferry Road, Columbia, SC, 29209, USA.
- University of South Carolina School of Medicine, Columbia, SC, USA.
| | | | | | | | | | | | - Mandeep S Sidhu
- Albany Medical College and Albany Medical Center, Albany, NY, USA
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16
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Fruchart JC, Hermans MP, Fruchart-Najib J. Selective Peroxisome Proliferator-Activated Receptor Alpha Modulators (SPPARMα): New Opportunities to Reduce Residual Cardiovascular Risk in Chronic Kidney Disease? Curr Atheroscler Rep 2020; 22:43. [PMID: 32671476 PMCID: PMC7363727 DOI: 10.1007/s11883-020-00860-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Chronic kidney disease (CKD) poses a major global challenge, which is exacerbated by aging populations and the pandemic of type 2 diabetes mellitus. Much of the escalating burden of CKD is due to cardiovascular complications. Current treatment guidelines for dyslipidemia in CKD prioritize low-density lipoprotein cholesterol management, but still leave a high residual cardiovascular risk. Targeting elevated triglycerides and low plasma high-density lipoprotein cholesterol, a common feature of CKD, could offer additional benefit. There are, however, safety issues with current fibrates (peroxisome proliferator-activated receptor alpha [PPARα] agonists), notably the propensity for elevation in serum creatinine, indicating the need for new approaches. RECENT FINDINGS Interactions between the ligand and PPARα receptor influence the specificity and potency of receptor binding, and downstream gene and physiological effects. The peroxisome proliferator-activated receptor alpha modulator (SPPARMα) concept aims to modulate the ligand structure so as to enhance binding at the PPARα receptor, thereby improving the ligand's selectivity, potency, and safety profile. This concept has led to the development of pemafibrate, a novel SPPARMα agent. This review discusses evidence that differentiates pemafibrate from current fibrates, especially the lack of evidence for elevation in serum creatinine or worsening of renal function in high-risk patients, including those with CKD. Differentiation of pemafibrate from current fibrates aims to address unmet clinical needs in CKD. The ongoing PROMINENT study will provide critical information regarding the long-term efficacy and safety of pemafibrate in patients with type 2 diabetes mellitus, including those with CKD, and whether the favorable lipid-modifying profile translates to reduction in residual cardiovascular risk.
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Affiliation(s)
- Jean-Charles Fruchart
- Residual Risk Reduction Initiative (R3i) Foundation, Picassoplatz 8, 4010, Basel, Switzerland.
| | - Michel P Hermans
- Division of Endocrinology and Nutrition, Cliniques Universitaires St-Luc and Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - Jamila Fruchart-Najib
- Residual Risk Reduction Initiative (R3i) Foundation, Picassoplatz 8, 4010, Basel, Switzerland
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17
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Pradhan A, Bhandari M, Sethi R. Ezetimibe and Improving Cardiovascular Outcomes: Current Evidence and Perspectives. Cardiol Res Pract 2020; 2020:9815016. [PMID: 32670636 PMCID: PMC7338976 DOI: 10.1155/2020/9815016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 05/11/2020] [Indexed: 02/05/2023] Open
Abstract
Low-density lipoprotein lowering with statins has convincingly and consistently proven to reduce cardiovascular events in both primary and secondary prevention. However, despite high-dose statin therapy, residual cardiovascular risk remains and many patients also do not tolerate statins. Ezetimibe was initially projected as a frontline alternative to statin. It is an intestinal cholesterol absorption inhibitor with modest LDL lowering effects. But, major studies failed to demonstrate any beneficial effect of CV outcomes, and the drug was relegated to oblivion. IMPROVE-IT, a contemporary, large, and well-designed trial, unequivocally demonstrated reduction in CV outcomes with ezetimibe when added to statin therapy. The benefits are seen in both sexes, elderly, CKD, diabetes mellitus, and in patients with prior CABG. It also reduces biomarkers and induces plaque regression like statins. The drug has now established itself as an add-on therapy to statin when monotherapy fails to achieve LDL goals and when it is not tolerated. The combination therapy has excellent safety and efficacy record. It has now been endorsed by major guidelines too in management of dyslipidemia. Yes, ezetimibe can indeed improve cardiovascular outcomes!
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Affiliation(s)
- Akshyaya Pradhan
- Department of Cardiology, King George's Medical University, Lucknow, Uttar Pradesh 226003, India
| | - Monika Bhandari
- Department of Cardiology, King George's Medical University, Lucknow, Uttar Pradesh 226003, India
| | - Rishi Sethi
- Department of Cardiology, King George's Medical University, Lucknow, Uttar Pradesh 226003, India
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18
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Lin YC, Lai TS, Wu HY, Chou YH, Chiang WC, Lin SL, Chen YM, Chu TS, Tu YK. Effects and Safety of Statin and Ezetimibe Combination Therapy in Patients with Chronic Kidney Disease: A Systematic Review and Meta-Analysis. Clin Pharmacol Ther 2020; 108:833-843. [PMID: 32320058 DOI: 10.1002/cpt.1859] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 03/25/2020] [Indexed: 12/31/2022]
Abstract
The efficacy and safety of statin and ezetimibe combination therapy in patients with chronic kidney disease (CKD) remains unclear. To assess the effect of statin and ezetimibe combination therapy on controlling lipid profiles and reducing cardiovascular events in patients with CKD, we conducted a systematic review and meta-analysis. We selected randomized controlled trials comparing this combination therapy with statin monotherapy or placebo in patients with CKD from the PubMed, Embase, and Cochrane Central Register of Controlled Trials databases published before September 1, 2018 on the Internet. Eight articles on seven studies, with a total of 14,016 patients with CKD, were selected from 412 full-text articles. Statin and ezetimibe combination therapy had beneficial effects on serum total cholesterol (weighted mean difference (WMD) -20.31 mg/dL, 95% confidence interval (CI), -26.87 to -13.75 mg/dL, P < 0.001), low-density lipoprotein cholesterol (WMD -17.22 mg/dL, 95% CI, -18.93 to -15.51 mg/dL, P < 0.001), and triglycerides (WMD -15.08 mg/dL, 95% CI, -23.41 to -6.75 mg/dL, P < 0.001) compared with statin monotherapy. Statin and ezetimibe combination therapy significantly reduced all-cause mortality and major adverse cardiovascular events (risk ratio 0.86, 95% CI, 0.77 to 0.97, P = 0.01). The incidence of adverse events was low, with no significant difference between statin and ezetimibe combination therapy and statin monotherapy. In conclusion, the statin and ezetimibe combination therapy significantly improved serum lipid profiles and reduced risks of all-cause deaths and major adverse cardiovascular events compared with the control group in patients with CKD.
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Affiliation(s)
- Yi-Chih Lin
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.,Department of Medicine, National Taiwan University Hospital Jinshan branch, New Taipei City, Taiwan.,Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Tai-Shuan Lai
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Hon-Yen Wu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Hsiang Chou
- Department of Medicine, National Taiwan University Hospital Jinshan branch, New Taipei City, Taiwan.,Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan.,Graduate Institute of Physiology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wen-Chih Chiang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Shuei-Liong Lin
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan.,Graduate Institute of Physiology, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.,Research Center for Developmental Biology and Regenerative Medicine, National Taiwan University, Taipei, Taiwan
| | - Yung-Ming Chen
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Tzong-Shinn Chu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.,Department of Dentistry and Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan.,Research center of big data and meta-analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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19
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Mohammadkhani N, Gharbi S, Rajani HF, Farzaneh A, Mahjoob G, Hoseinsalari A, Korsching E. Statins: Complex outcomes but increasingly helpful treatment options for patients. Eur J Pharmacol 2019; 863:172704. [DOI: 10.1016/j.ejphar.2019.172704] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/25/2019] [Accepted: 09/26/2019] [Indexed: 12/15/2022]
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20
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Katsiki N, Mikhailidis DP, Banach M. Lipid-lowering agents for concurrent cardiovascular and chronic kidney disease. Expert Opin Pharmacother 2019; 20:2007-2017. [DOI: 10.1080/14656566.2019.1649394] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Niki Katsiki
- Diabetes Center, Division of Endocrinology and Metabolism, First Department of Internal Medicine, AHEPA University Hospital, Medical School Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Maciej Banach
- Department of Hypertension, WAM University Hospital in Lodz, Medical University of Lodz, Lodz, Poland
- Polish Mother’s Memorial Hospital Research Institute (PMMHRI), Lodz, Poland
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21
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Charytan DM, Sabatine MS, Pedersen TR, Im K, Park JG, Pineda AL, Wasserman SM, Deedwania P, Olsson AG, Sever PS, Keech AC, Giugliano RP. Efficacy and Safety of Evolocumab in Chronic Kidney Disease in the FOURIER Trial. J Am Coll Cardiol 2019; 73:2961-2970. [DOI: 10.1016/j.jacc.2019.03.513] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 03/10/2019] [Accepted: 03/19/2019] [Indexed: 10/26/2022]
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22
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Schmidt IM, Hübner S, Nadal J, Titze S, Schmid M, Bärthlein B, Schlieper G, Dienemann T, Schultheiss UT, Meiselbach H, Köttgen A, Flöge J, Busch M, Kreutz R, Kielstein JT, Eckardt KU. Patterns of medication use and the burden of polypharmacy in patients with chronic kidney disease: the German Chronic Kidney Disease study. Clin Kidney J 2019; 12:663-672. [PMID: 31584562 PMCID: PMC6768303 DOI: 10.1093/ckj/sfz046] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Indexed: 02/06/2023] Open
Abstract
Background Patients with chronic kidney disease (CKD) bear a substantial burden of comorbidities leading to the prescription of multiple drugs and a risk of polypharmacy. However, data on medication use in this population are scarce. Methods A total of 5217 adults with an estimated glomerular filtration rate (eGFR) between 30 and 60 mL/min/1.73 m2 or an eGFR ≥60 mL/min/1.73m2 and overt proteinuria (>500 mg/day) were studied. Self-reported data on current medication use were assessed at baseline (2010-12) and after 4 years of follow-up (FU). Prevalence and risk factors associated with polypharmacy (defined as the regular use of five or more drugs per day) as well as initiation or termination of polypharmacy were evaluated using multivariable logistic regression. Results The prevalence of polypharmacy at baseline and FU was almost 80%, ranging from 62% in patients with CKD Stage G1 to 86% in those with CKD Stage G3b. The median number of different medications taken per day was eight (range 0-27). β-blockers, angiotensin-converting enzyme inhibitors and statins were most frequently used. Increasing CKD G stage, age and body mass index, diabetes mellitus, cardiovascular disease and a history of smoking were significantly associated with both the prevalence of polypharmacy and its maintenance during FU. Diabetes mellitus was also significantly associated with the initiation of polypharmacy [odds ratio (OR) 2.46, (95% confidence interval 1.36-4.45); P = 0.003]. Conclusion Medication burden in CKD patients is high. Further research appears warranted to address the implications of polypharmacy, risks of drug interactions and strategies for risk reduction in this vulnerable patient population.
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Affiliation(s)
- Insa M Schmidt
- Department of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Silvia Hübner
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Jennifer Nadal
- Department of Medical Biometry, Informatics, and Epidemiology, University Hospital, Bonn, Germany
| | - Stephanie Titze
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Matthias Schmid
- Department of Medical Biometry, Informatics, and Epidemiology, University Hospital, Bonn, Germany
| | - Barbara Bärthlein
- Department of Medical Informatics, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany.,Medical Centre for Information and Communication Technology, University Hospital Erlangen, Erlangen, Germany
| | - Georg Schlieper
- Division of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Thomas Dienemann
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Ulla T Schultheiss
- Institute of Genetic Epidemiology, Faculty of Medicine and Medical Center-University of Freiburg, Freiburg, Germany
| | - Heike Meiselbach
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Anna Köttgen
- Institute of Genetic Epidemiology, Faculty of Medicine and Medical Center-University of Freiburg, Freiburg, Germany
| | - Jürgen Flöge
- Division of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Martin Busch
- Department of Internal Medicine III, University Hospital Jena, Jena, Germany
| | - Reinhold Kreutz
- Department of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jan T Kielstein
- Medical Clinic V - Nephrology, Rheumatology, Blood Purification, Academic Teaching Hospital Braunschweig, Braunschweig, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany.,Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Scognamiglio M, Costa D, Sorriento A, Napoli C. Current Drugs and Nutraceuticals for the Treatment of Patients with Dyslipidemias. Curr Pharm Des 2019; 25:85-95. [DOI: 10.2174/1381612825666190130101108] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/20/2019] [Indexed: 02/05/2023]
Abstract
Coronary heart disease (CHD) remains the leading cause of disability and death in industrialized Countries.
Among many conditions, which contribute to the etiology and progression of CHD, the presence of high
low density lipoprotein-cholesterol (LDL-C) levels represents the major risk factor. Therefore, the reduction of
LDL-C levels plays a key role in the management of patients with high or very high cardiovascular risk. Although
statins represent the gold standard therapy for the reduction of cholesterol levels, these drugs do not allow to
achieve target levels of LDL-C in all patients. Indeed, a significant number of patients resulted intolerants, especially
when the dosage increased. The availability of new lipid-lowering drugs, such as ezetimibe and PCSK9
inhibitors, may represent an important alternative or complement to the conventional lipid-lowering therapies.
However, long-term studies are still needed to define both efficacy and safety of use of these latter new drugs.
Some nutraceuticals may become an adequate and effective support in the management of some patients. To date,
several nutraceuticals with different mechanism of actions that provide a good tolerability are available as lipidlowering
agents. In particular, the most investigated are red yeast rice, phytosterols, berberine, beta-glucans and
soy. The aim of this review was to report recent data on the efficacy and safety of principle hypocholesterolemic
drugs available and to evaluate the possible role of some nutraceuticals as support therapy in the management of
patients with dyslipidemias.
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Affiliation(s)
- Michele Scognamiglio
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Clinical Department of Internal Medicine and Specialistics, Department of Medical, Surgical, Neurological, Metabolic and Geriatric Sciences, University of Campania , Italy
| | - Dario Costa
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Clinical Department of Internal Medicine and Specialistics, Department of Medical, Surgical, Neurological, Metabolic and Geriatric Sciences, University of Campania , Italy
| | - Antonio Sorriento
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Clinical Department of Internal Medicine and Specialistics, Department of Medical, Surgical, Neurological, Metabolic and Geriatric Sciences, University of Campania , Italy
| | - Claudio Napoli
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Clinical Department of Internal Medicine and Specialistics, Department of Medical, Surgical, Neurological, Metabolic and Geriatric Sciences, University of Campania , Italy
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24
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Streja E, Streja DA, Soohoo M, Kleine CE, Hsiung JT, Park C, Moradi H. Precision Medicine and Personalized Management of Lipoprotein and Lipid Disorders in Chronic and End-Stage Kidney Disease. Semin Nephrol 2019; 38:369-382. [PMID: 30082057 DOI: 10.1016/j.semnephrol.2018.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Precision medicine is an emerging field that calls for individualization of treatment strategies based on characteristics unique to each patient. In lipid management, current guidelines are driven mainly by clinical trial results that presently indicate that patients with non-dialysis-dependent chronic kidney disease (CKD) should be treated with a β-hydroxy β-methylglutaryl-CoA reductase inhibitor, also known as statin therapy. For patients with end-stage kidney disease (ESKD) being treated with hemodialysis, statin therapy has not been shown to successfully reduce poor outcomes in trials and therefore is not recommended. The two major guidelines dissent on whether statin therapy should be of moderate or high intensity in non-dialysis-dependent CKD patients, but often leave the prescribing clinician to make that decision. These decisions often are complicated by the increased concerns for adverse events such as myopathies in patients with advanced kidney disease and ESKD. In the future, there may be an opportunity to further identify CKD and ESKD patients who are more likely to benefit from lipid-modifying therapy as opposed to those who likely will suffer from its side effects using precision medicine tools. For now, data from genetics studies and subgroup analyses may provide insight for future research directions in this field and we review some of the work that has been published in this regard.
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Affiliation(s)
- Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA.; Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA..
| | - Dan A Streja
- Division of Endocrinology, Diabetes and Metabolism, West Los Angeles VA Medical Center, Greater Los Angeles VA Healthcare System, Los Angeles, CA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA.; Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - Carola-Ellen Kleine
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA.; Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - Jui-Ting Hsiung
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA.; Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - Christina Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA.; Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - Hamid Moradi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA.; Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
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Obialo CI, Ofili EO, Norris KC. Statins and Cardiovascular Disease Outcomes in Chronic Kidney Disease: Reaffirmation vs. Repudiation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E2733. [PMID: 30518032 PMCID: PMC6313800 DOI: 10.3390/ijerph15122733] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 11/28/2018] [Accepted: 11/30/2018] [Indexed: 12/11/2022]
Abstract
Cardiovascular disease (CVD) burden is several-fold higher in patients with chronic kidney disease (CKD). Although statins have been shown to provide significant CVD benefits in both the general population and patients with CKD, this has not translated into survival advantage in patients with advanced CKD or on dialysis. It has been reported that CVD risk continues to escalate as CKD progresses to end-stage kidney disease (ESKD); however, the CVD risk reduction by statins appears to decline as patients' progress from the early to later stages of CKD. Statins have also been associated with a higher incidence of stroke in ESKD patients. Thus, the CVD benefits of statins in ESKD remain questionable.
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Affiliation(s)
- Chamberlain I Obialo
- Department of Medicine, Morehouse School of Medicine, Atlanta, GA 30310-1495, USA.
| | - Elizabeth O Ofili
- Department of Medicine, Morehouse School of Medicine, Atlanta, GA 30310-1495, USA.
| | - Keith C Norris
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90024, USA.
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Katsiki N, Mikhailidis DP. Lipids: a personal view of the past decade. Hormones (Athens) 2018; 17:461-478. [PMID: 30229482 DOI: 10.1007/s42000-018-0058-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 08/31/2018] [Indexed: 12/27/2022]
Abstract
The past decade has witnessed considerable progress in the field of lipids. New drugs have been "rapidly" developed and some of these drugs have already been evaluated in event-based large trials. This evidence has led to the guidelines recommending new, more aggressive treatment goals for low-density lipoprotein cholesterol (LDL-C) levels. Although LDL-C remains the principal goal for cardiovascular disease (CVD) risk reduction, there has also been considerable interest in other lipid variables, such as high-density lipoprotein cholesterol, triglycerides, and lipoprotein(a). Statin intolerance is now considered a very important topic in daily clinical practice. This has resulted in more attention focusing on non-statin drugs [e.g., ezetimibe and proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors] and statin-related side effects. The latter mainly involve muscles, but there is also a need to consider other adverse effects associated with statin use (e.g., new onset diabetes). New specific areas of statin use have attracted interest. For example, statin-loading before procedures (e.g., coronary stenting), the prevention of stroke, and the treatment of non-alcoholic fatty liver disease (NAFLD). Statins will remain the most widely used drugs to treat dyslipidaemia and decrease CVD risk. However, we also need to briefly consider some other lipid-lowering drugs, including those that may become available in the future.
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Affiliation(s)
- Niki Katsiki
- Second Department of Propaedeutic Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Thessaloniki, Greece
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), Pond Street, London, NW3 2QG, UK.
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Zhan S, Tang M, Liu F, Xia P, Shu M, Wu X. Ezetimibe for the prevention of cardiovascular disease and all-cause mortality events. Cochrane Database Syst Rev 2018; 11:CD012502. [PMID: 30480766 PMCID: PMC6516816 DOI: 10.1002/14651858.cd012502.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Cardiovascular disease (CVD) remains an important cause of mortality and morbidity, and high levels of blood cholesterol are thought to be the major modifiable risk factors for CVD. The use of statins is the preferred treatment strategy for the prevention of CVD, but some people at high-risk for CVD are intolerant to statin therapy or unable to achieve their treatment goals with the maximal recommended doses of statin. Ezetimibe is a selective cholesterol absorption inhibitor, whether it has a positive effect on CVD events remains uncertain. Results from clinical studies are inconsistent and a thorough evaluation of its efficacy and safety for the prevention of CVD and mortality is necessary. OBJECTIVES To assess the efficacy and safety of ezetimibe for the prevention of CVD and all-cause mortality. SEARCH METHODS We searched the CENTRAL, MEDLINE, Embase and Web of Science on 27 June 2018, and two clinical trial registry platforms on 11 July 2018. We checked reference lists from primary studies and review articles for additional studies. No language restrictions were applied. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared ezetimibe versus placebo or ezetimibe plus other lipid-modifying drugs versus other lipid-modifying drugs alone in adults, with or without CVD, and which had a follow-up of at least 12 months. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data, assessed risk of bias and contacted trialists to obtain missing data. We performed statistical analyses according to the Cochrane Handbook for Systematic Reviews of Interventions and used the GRADE to assess the quality of evidence. MAIN RESULTS We included 26 RCTs randomising 23,499 participants. All included studies assessed effects of ezetimibe plus other lipid-modifying drugs compared with other lipid-modifying drugs alone or plus placebo. Our findings were driven by the largest study (IMPROVE-IT), which had weights ranging from 41.5% to 98.4% in the different meta-analyses.Ezetimibe with statins probably reduces the risk of major adverse cardiovascular events compared with statins alone (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.90 to 0.98; a decrease from 284/1000 to 267/1000, 95% CI 256 to 278; 21,727 participants; 10 studies; moderate-quality evidence). Trials reporting all-cause mortality used ezetimibe with statin or fenofibrate and found they have little or no effect on this outcome (RR 0.98, 95% CI 0.91 to 1.05; 21,222 participants; 8 studies; high-quality evidence). Adding ezetimibe to statins probably reduces the risk of non-fatal myocardial infarction (MI) (RR 0.88, 95% CI 0.81 to 0.95; a decrease from 105/1000 to 92/1000, 95% CI 85 to 100; 21,145 participants; 6 studies; moderate-quality evidence) and non-fatal stroke (RR 0.83, 95% CI 0.71 to 0.97; a decrease 32/1000 to 27/1000, 95% CI 23 to 31; 21,205 participants; 6 studies; moderate-quality evidence). Trials reporting cardiovascular mortality added ezetimibe to statin or fenofibrate, probably having little or no effect on this outcome (RR 1.00, 95% CI 0.89 to 1.12; 19457 participants; 6 studies; moderate-quality evidence). The need for coronary revascularisation might be reduced by adding ezetimibe to statin (RR 0.94, 95% CI 0.89 to 0.99; a decrease from 196/1000 to 184/1000, 95% 175 to 194; 21,323 participants; 7 studies); however, no difference in coronary revascularisation rate was observed when a sensitivity analysis was limited to studies with a low risk of bias.In terms of safety, adding ezetimibe to statins may make little or no difference in the risk of hepatopathy (RR 1.14, 95% CI 0.96 to 1.35; 20,687 participants; 4 studies; low-quality evidence). It is uncertain whether ezetimibe increase or decrease the risk of myopathy (RR 1.31, 95% CI 0.72 to 2.38; 20,581 participants; 3 studies; very low-quality evidence) and rhabdomyolysis, given the wide CIs and low event rate. Little or no difference in the risk of cancer, gallbladder-related disease and discontinuation due to adverse events were observed between treatment groups. For serum lipids, adding ezetimibe to statin or fenofibrate might further reduce the low-density lipoprotein cholesterol (LDL-C), total cholesterol and triglyceride levels and likely increase the high-density lipoprotein cholesterol levels; however, substantial heterogeneity was detected in most analyses.None of the included studies reported on health-related quality of life. AUTHORS' CONCLUSIONS Moderate- to high-quality evidence suggests that ezetimibe has modest beneficial effects on the risk of CVD endpoints, primarily driven by a reduction in non-fatal MI and non-fatal stroke, but it has little or no effect on clinical fatal endpoints. The cardiovascular benefit of ezetimibe might involve the reduction of LDL-C, total cholesterol and triglycerides. There is insufficient evidence to determine whether ezetimibe increases the risk of adverse events due to the low and very low quality of the evidence. The evidence for beneficial effects was mainly obtained from individuals with established atherosclerotic cardiovascular disease (ASCVD, predominantly with acute coronary syndrome) administered ezetimibe plus statins. However, there is limited evidence regarding the role of ezetimibe in primary prevention and the effects of ezetimibe monotherapy in the prevention of CVD, and these topics thus requires further investigation.
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Affiliation(s)
- Shipeng Zhan
- First Affiliated Hospital of Third Military Medical University (Army Medical University)Pharmacy Department30 Gaotanyan StreetShapingba DistrictChongqingChina400038
| | - Min Tang
- First Affiliated Hospital of Third Military Medical University (Army Medical University)Pharmacy Department30 Gaotanyan StreetShapingba DistrictChongqingChina400038
| | - Fang Liu
- First Affiliated Hospital of Third Military Medical University (Army Medical University)Pharmacy Department30 Gaotanyan StreetShapingba DistrictChongqingChina400038
| | - Peiyuan Xia
- First Affiliated Hospital of Third Military Medical University (Army Medical University)Pharmacy Department30 Gaotanyan StreetShapingba DistrictChongqingChina400038
| | - Maoqin Shu
- First Affiliated Hospital of Third Military Medical University (Army Medical University)Cardiovascular DepartmentChongqingChina
| | - Xiaojiao Wu
- Third Military Medical University (Army Medical University)Department of Health Statistics, College of Preventive MedicineChongqingChina
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Bove M, Fogacci F, Cicero AFG. Pharmacokinetic drug evaluation of ezetimibe + simvastatin for the treatment of hypercholesterolemia. Expert Opin Drug Metab Toxicol 2017; 13:1099-1104. [DOI: 10.1080/17425255.2017.1381085] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Marilisa Bove
- Internal and Surgical Medicine Sciences Department, University of Bologna, Bologna, Italy
| | - Federica Fogacci
- Internal and Surgical Medicine Sciences Department, University of Bologna, Bologna, Italy
| | - Arrigo F. G. Cicero
- Internal and Surgical Medicine Sciences Department, University of Bologna, Bologna, Italy
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