A case report: Acute kidney injury with progression to chronicity in an eldery woman

Acute renal failure in elderly patients can be caused by a wide spectrum of diseases that usually have a cause outside the kidney. The most common causes include renal impairment as part of ANCA vasculitis, another category includes clonal plasmatic cell disease with light chain cast nephropathy; and there also exists an increasing number of drug-induced tubulointerstial damage. We present a case of iatrogenic less common form of acute failure in a 73-year-old woman, who did not suffer from any serious disease until then. Although the biopsy helped to determine the cause of the failure and thus affect subsequent therapy, the function did not return to the previous state and the patient progressed to CKD G3bA1 with serum creatinine values of around 170-140 μmol/l.

Statins and liver

Statins are widely accepted hypolipidemics that work by inhibiting hydroxymethylglutaryl coenzyme A reductase and thereby inhibiting cholesterol synthesis. They significantly reduce cardiovascular risk. Their use could be associated with side effects, which are serious only in rare cases. However, an unhealthy lifestyle, obesity, and elevation of blood lipids do not only damage the cardiovascular system. The current topic not only in hepatology is non-alcoholic fatty liver disease - NAFLD. The aim of this article is, among others, to draw attention to the pleiotropic effects of statins, which could be used in the treatment of this disease in the future. Recent studies have suggested that the administration of statins to patients with NAFLD is beneficial.

New technology in the hypolipidemic drugs development. Inclisiran (LEQVIO)

The development of lipid modifying drugs was expanding during the past 30 years. Statins stay to be the first choice drugs in dyslipidemia treatment. Inhibitors of proprotein convertase subtilisin- kexin type 9 (PCSK9) enzyme in combination with statin and/or ezetimibe represent very effective therapy and better atherosclerotic cardiovascular disease (ASCVD) prevention. Antisense therapy based on oligonucleotides belongs to the new technology drugs. This therapy inhibits translation of some proteins important for the production of atherogenic lipid particles. Inclisiran is a small interfering RNA that suppresses translation of PCSK9 in the liver cells. It is applied subcutaneously twice a year and it represents a big chance for the improvement of ASCVD treatment and prevention.

Don't we forget about biological therapy of hypercholesterolemia with PCSK9-inhibitors?

In many patients it is difficult to achieve the current very low target LDL-cholesterol levels, recommended for the prevention of atherosclerotic cardiovascular events. If statin therapy or statins in combination with ezetimibe are not sufficient, addition of PCSK9 inhibitors should be considered. PCSK9 inhibitors reduce LDL-CH by an average of 50-60 % and reduce the risk of atherosclerotic cardiovascular events. They are currently reserved for patients with atherosclerotic cardiovascular disease and for patients with familial hypercholesterolaemia, in whom despite intensive hypolipidemic therapy statins with ezetimibe the target LDL-cholesterol value is not reached. In these patients, PCSK9 inhibitors may also be indicated in case of statin intolerance.

Vascular age

Age can be evaluated according to many criteria. Of course the objective measure is the calendar age which may differ from the biological age. The biological age more or less correlates with the vascular age. The concept of vascular age is based on the statement that “An individual is as old as his blood vessels”. The process of vascular aging already starts in childhood. Arterial aging may essentially be viewed from two standpoints. First, it involves stiffening of arteries and loss of their elasticity; second, degenerative changes and formation of atherosclerotic plaques occur, being the cause of ischemia, especially in case of the development of atherothrombosis. Both these processes can be monitored: The change of elasticity (arteriosclerosis) mainly by examination of pulse wave velocity (PWV), atherosclerosis then primarily with non-invasive methods, ultrasound or CT angiography examination. From the clinical point of view it is particularly important whether we can influence vascular age in some way. Evidence is available now that atherosclerosis can be affected by hypolipidemic treatment, arteriosclerosis then in particular by ACE inhibitors. The aforementioned possibility of influencing vascular age brings us to another problem, which is compliance of patients. With regard to that it is good that in a situation where we have two drugs affecting vascular age, we can use their fixed combination. It is available as a combination of atorvastatin and perindopril.

Notes on the new “Recommendations for the treatment of dyslipidemia. Influencing of lipids to reduce cardiovascular risk&#8221

New guidelines on dyslipidemia (DLP) related problems appear earlier than planned. Primarily in view of the results of science and large clinical studies, but also with regard to the advent of biological therapy (PCSK9-i) in many Euro-pean countries. Also, the “conventional” hypolipidemic therapy is generified and therefore cheaper, more af-fordable. The recommendations are based, as the preceding ones, on the principle of estimating the overall cardiovascular risk. The innovated SCORE tables are used for this, but more emphasis is placed on non-invasive dia-gnostics using imaging methods, be it carotid ultrasound or, in particular, non-contrast CT coronarography. Perhaps the most significant outcome is the reduction of LDL-cholesterol (LDL-C) target values to 1.4 mmol/l and a 50% reduction of baseline LDL-C in patients belonging to the highest risk groups, and in secondary prevention. Moreover, in the case of “extreme” risk the goal is to reduce LDL-C below 1 mmol/l. Essential to DLP therapy is statin treatment. Especially in patients with acute coronary syndrome and those in the highest risk categories, the maximum tolerated doses of statin should be used, if necessary in combination with ezetimibe. Where this maximum “routine” treatment is insufficient to achieve the target values, PCSK9-i therapy is indicated. However the recommendations do not by any means omit non-pharmacological therapy, quite the opposite, it is always emphasized as the first step of DLP therapy. Worthy of notice is the introduction of the term “atherosclerotic cardiovascular disease” - ASCVD, which replaces the older and less accurate CVD.