American Journal of Kidney Diseases

KDOQI US Commentary on the 2013 KDIGO Clinical Practice Guideline for Lipid Management in CKD

Published:November 17, 2014DOI:
      The National Kidney Foundation–Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guideline for management of dyslipidemia in chronic kidney disease (CKD) was published in 2003. Since then, considerable evidence, including randomized controlled trials of statin therapy in adults with CKD, has helped better define medical treatments for dyslipidemia. In light of the new evidence, KDIGO (Kidney Disease: Improving Global Outcomes) formed a work group for the management of dyslipidemia in patients with CKD. This work group developed a new guideline that contains substantial changes from the prior KDOQI guideline. KDIGO recommends treatment of dyslipidemia in patients with CKD primarily based on risk for coronary heart disease, which is driven in large part by age. The KDIGO guideline does not recommend using low-density lipoprotein cholesterol level as a guide for identifying individuals with CKD to be treated or as treatment targets. Initiation of statin treatment is no longer recommended in dialysis patients. To assist US practitioners in interpreting and applying the KDIGO guideline, NKF-KDOQI convened a work group to write a commentary on this guideline. For the most part, our work group agreed with the recommendations of the KDIGO guideline, although we describe several areas in which we believe the guideline statements are either too strong or need to be more nuanced, areas of uncertainty and inconsistency, as well as additional research recommendations. The target audience for the KDIGO guideline includes nephrologists, primary care practitioners, and non-nephrology specialists such as cardiologists and endocrinologists. As such, we also put the current recommendations into the context of other clinical practice recommendations for cholesterol treatment.

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        • National Kidney Foundation
        K/DOQI clinical practice guidelines for management of dyslipidemias in patients with kidney disease.
        Am J Kidney Dis. 2003; 41 (S1-S91): I-IV
        • Wanner C.
        • Krane V.
        • Marz W.
        • et al.
        Atorvastatin in patients with type 2 diabetes mellitus undergoing hemodialysis.
        N Engl J Med. 2005; 353: 238-248
        • Fellstrom B.C.
        • Jardine A.G.
        • Schmieder R.E.
        • et al.
        Rosuvastatin and cardiovascular events in patients undergoing hemodialysis.
        N Engl J Med. 2009; 360: 1395-1407
        • Baigent C.
        • Landray M.J.
        • Reith C.
        • et al.
        The effects of lowering LDL cholesterol with simvastatin plus ezetimibe in patients with chronic kidney disease (Study of Heart and Renal Protection): a randomised placebo-controlled trial.
        Lancet. 2011; 377: 2181-2192
        • Stone N.J.
        • Robinson J.
        • Lichtenstein A.H.
        • et al.
        2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
        Circulation. 2014; 129: S1-S45
        • Debella Y.T.
        • Giduma H.D.
        • Light R.P.
        • Agarwal R.
        Chronic kidney disease as a coronary disease equivalent—a comparison with diabetes over a decade.
        Clin J Am Soc Nephrol. 2011; 6: 1385-1392
        • Tonelli M.
        • Muntner P.
        • Lloyd A.
        • et al.
        Impact of age on the association between CKD and the risk of future coronary events.
        Am J Kidney Dis. 2014; 64: 375-382
        • Wanner C.
        • Tonelli M.
        KDIGO clinical practice guideline for lipid management in CKD: summary of recommendation statements and clinical approach to the patient.
        Kidney Int. 2014; 85: 1303-1309
        • Kidney Disease: Improving Global Outcomes (KDIGO) Lipid Work Group
        KDIGO clinical practice guideline for lipid managment in chronic kidney disease.
        Kidney Int Suppl. 2013; 3: 259-305
        • Chang A.
        • Kramer H.
        Should eGFR and albuminuria be added to the Framingham risk score? Chronic kidney disease and cardiovascular disease risk prediction.
        Nephron Clin Pract. 2011; 119 (discussion c177-c178): c171-c177
        • Drawz P.E.
        • Baraniuk S.
        • Davis B.R.
        • et al.
        Cardiovascular risk assessment: addition of CKD and race to the Framingham equation.
        Am Heart J. 2012; 164 (e922): 925-931
        • Nishimura K.
        • Okamura T.
        • Watanabe M.
        • et al.
        Predicting coronary heart disease using risk factor categories for a Japanese urban population, and comparison with the Framingham risk score: the Suita Study.
        J Atheroscler Thromb. 2014; 21: 784-798
        • Weiner D.E.
        • Tighiouart H.
        • Elsayed E.F.
        • et al.
        The Framingham predictive instrument in chronic kidney disease.
        J Am Coll Cardiol. 2007; 50: 217-224
        • Weiner D.E.
        • Tighiouart H.
        • Griffith J.L.
        • et al.
        Kidney disease, Framingham risk scores, and cardiac and mortality outcomes.
        Am J Med. 2007; 120: 552.e1-552.e8
        • Chang T.I.
        • Desai M.
        • Solomon D.H.
        • Winkelmayer W.C.
        Kidney function and long-term medication adherence after myocardial infarction in the elderly.
        Clin J Am Soc Nephrol. 2011; 6: 864-869
        • Krousel-Wood M.
        • Thomas S.
        • Muntner P.
        • Morisky D.
        Medication adherence: a key factor in achieving blood pressure control and good clinical outcomes in hypertensive patients.
        Curr Opin Cardiol. 2004; 19: 357-362
        • Dunbar-Jacob J.
        • Sereika S.M.
        • Houze M.
        • Luyster F.S.
        • Callan J.A.
        Accuracy of measures of medication adherence in a cholesterol-lowering regimen.
        West J Nurs Res. 2012; 34: 578-597
        • Baigent C.
        • Blackwell L.
        • Emberson J.
        • et al.
        Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials.
        Lancet. 2010; 376: 1670-1681
        • Shepherd J.
        • Kastelein J.J.
        • Bittner V.
        • et al.
        Intensive lipid lowering with atorvastatin in patients with coronary heart disease and chronic kidney disease: the TNT (Treating to New Targets) Study.
        J Am Coll Cardiol. 2008; 51: 1448-1454
        • Glasziou P.P.
        • Irwig L.
        • Heritier S.
        • Simes R.J.
        • Tonkin A.
        Monitoring cholesterol levels: measurement error or true change?.
        Ann Intern Med. 2008; 148: 656-661
        • Goff Jr., D.C.
        • Lloyd-Jones D.M.
        • Bennett G.
        • et al.
        2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
        J Am Coll Cardiol. 2014; 63: 2935-2959
        • Palmer S.C.
        • Navaneethan S.D.
        • Craig J.C.
        • et al.
        HMG CoA reductase inhibitors (statins) for people with chronic kidney disease not requiring dialysis.
        Cochrane Database Syst Rev. 2014; 5: CD007784
        • Hallan S.I.
        • Matsushita K.
        • Sang Y.
        • et al.
        Age and association of kidney measures with mortality and end-stage renal disease.
        JAMA. 2012; 308: 2349-2360
        • Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group
        KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.
        Kidney Int Suppl. 2013; 3: 1-150
        • Tonelli M.
        • Jose P.
        • Curhan G.
        • Sacks F.
        • Braunwald E.
        • Pfeffer M.
        Proteinuria, impaired kidney function, and adverse outcomes in people with coronary disease: analysis of a previously conducted randomised trial.
        BMJ. 2006; 332: 1426
        • Colhoun H.M.
        • Betteridge D.J.
        • Durrington P.N.
        • et al.
        Effects of atorvastatin on kidney outcomes and cardiovascular disease in patients with diabetes: an analysis from the Collaborative Atorvastatin Diabetes Study (CARDS).
        Am J Kidney Dis. 2009; 54: 810-819
        • Asselbergs F.W.
        • Diercks G.F.
        • Hillege H.L.
        • et al.
        Effects of fosinopril and pravastatin on cardiovascular events in subjects with microalbuminuria.
        Circulation. 2004; 110: 2809-2816
        • Kronenberg F.
        Dyslipidemia and nephrotic syndrome: recent advances.
        J Ren Nutr. 2005; 15: 195-203
        • Diaz J.M.
        • Gich I.
        • Bonfill X.
        • et al.
        Prevalence evolution and impact of cardiovascular risk factors on allograft and renal transplant patient survival.
        Transplant Proc. 2009; 41: 2151-2155
        • Phillips S.
        • Heuberger R.
        Metabolic disorders following kidney transplantation.
        J Ren Nutr. 2012; 22 (e451): 451-460
        • Vanrenterghem Y.F.
        • Claes K.
        • Montagnino G.
        • et al.
        Risk factors for cardiovascular events after successful renal transplantation.
        Transplantation. 2008; 85: 209-216
        • Kasiske B.
        • Cosio F.G.
        • Beto J.
        • et al.
        Clinical practice guidelines for managing dyslipidemias in kidney transplant patients: a report from the Managing Dyslipidemias in Chronic Kidney Disease Work Group of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative.
        Am J Transplant. 2004; : 13-53
        • Kasiske B.L.
        • Zeier M.G.
        • Craig J.C.
        • et al.
        KDIGO clinical practice guideline for the care of kidney transplant recipients.
        Am J Transplant. 2009; 9: S1-S155
        • Holdaas H.
        • Fellstrom B.
        • Jardine A.G.
        • et al.
        Effect of fluvastatin on cardiac outcomes in renal transplant recipients: a multicentre, randomised, placebo-controlled trial.
        Lancet. 2003; 361: 2024-2031
        • Jardine A.G.
        • Fellstrom B.
        • Logan J.O.
        • et al.
        Cardiovascular risk and renal transplantation: post hoc analyses of the Assessment of Lescol in Renal Transplantation (ALERT) Study.
        Am J Kidney Dis. 2005; 46: 529-536
        • Downs J.R.
        • Clearfield M.
        • Weis S.
        • et al.
        Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels: results of AFCAPS/TexCAPS. Air Force/Texas Coronary Atherosclerosis Prevention Study.
        JAMA. 1998; 279: 1615-1622
        • Organ Procurement and Transplantation Network (OPTN) and Scientific Registry of Transplant Recipients (SRTR)
        OPTN/SRTR 2011 Annual Data Report.
        Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation, Rockville, MD2012
        • Lemahieu W.P.
        • Maes B.D.
        • Verbeke K.
        • Vanrenterghem Y.
        CYP3A4 and P-glycoprotein activity in healthy controls and transplant patients on cyclosporin vs. tacrolimus vs. sirolimus.
        Am J Transplant. 2004; 4: 1514-1522
        • Lemahieu W.P.
        • Hermann M.
        • Asberg A.
        • et al.
        Combined therapy with atorvastatin and calcineurin inhibitors: no interactions with tacrolimus.
        Am J Transplant. 2005; 5: 2236-2243
        • Shitara Y.
        • Takeuchi K.
        • Nagamatsu Y.
        • Wada S.
        • Sugiyama Y.
        • Horie T.
        Long-lasting inhibitory effects of cyclosporin A, but not tacrolimus, on OATP1B1- and OATP1B3-mediated uptake.
        Drug Metab Pharmacokinet. 2012; 27: 368-378
        • Sayin B.
        • Karakayali H.
        • Colak T.
        • et al.
        Conversion to sirolimus for chronic allograft nephropathy and calcineurin inhibitor toxicity and the adverse effects of sirolimus after conversion.
        Transplant Proc. 2009; 41: 2789-2793
      1. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: summary report.
        Pediatrics. 2011; 128: S213-S256
        • Kavey R.E.
        • Allada V.
        • Daniels S.R.
        • et al.
        Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics.
        Circulation. 2006; 114: 2710-2738
        • Wilson A.C.
        • Schneider M.F.
        • Cox C.
        • et al.
        Prevalence and correlates of multiple cardiovascular risk factors in children with chronic kidney disease.
        Clin J Am Soc Nephrol. 2011; 6: 2759-2765
        • Ardissino G.
        • Dacco V.
        • Testa S.
        • et al.
        Epidemiology of chronic renal failure in children: data from the ItalKid project.
        Pediatrics. 2003; 111: e382-e387
        • Smith J.M.
        • Stablein D.M.
        • Munoz R.
        • Hebert D.
        • McDonald R.A.
        Contributions of the Transplant Registry: the 2006 Annual Report of the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS).
        Pediatr Transplant. 2007; 11: 366-373
        • Collins A.J.
        • Foley R.N.
        • Chavers B.
        • et al.
        US Renal Data System 2013 annual data report.
        Am J Kidney Dis. 2014; 63: e1-e420
      2. US Renal Data System. USRDS 2007 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (includes Special Request, Table H.13 Combined Transplant and Dialysis Groups). USRDS Coordinating Center UR. Accessed August 7, 2008.

        • Groothoff J.W.
        • Gruppen M.P.
        • Offringa M.
        • et al.
        Mortality and causes of death of end-stage renal disease in children: a Dutch cohort study.
        Kidney Int. 2002; 61: 621-629
        • Gruppen M.P.
        • Groothoff J.W.
        • Prins M.
        • et al.
        Cardiac disease in young adult patients with end-stage renal disease since childhood: a Dutch cohort study.
        Kidney Int. 2003; 63: 1058-1065
        • McDonald S.P.
        • Craig J.C.
        Long-term survival of children with end-stage renal disease.
        N Engl J Med. 2004; 350: 2654-2662
        • Kupferman J.C.
        • Aronson Friedman L.
        • Cox C.
        • et al.
        BP control and left ventricular hypertrophy regression in children with CKD.
        J Am Soc Nephrol. 2014; 25: 167-174
        • Kupferman J.C.
        • Paterno K.
        • Mahgerefteh J.
        • et al.
        Improvement of left ventricular mass with antihypertensive therapy in children with hypertension.
        Pediatr Nephrol. 2010; 25: 1513-1518
        • Brady T.M.
        • Schneider M.F.
        • Flynn J.T.
        • et al.
        Carotid intima-media thickness in children with CKD: results from the CKiD Study.
        Clin J Am Soc Nephrol. 2012; 7: 1930-1937
        • Appel-Dingemanse S.
        • Smith T.
        • Merz M.
        Pharmacokinetics of fluvastatin in subjects with renal impairment and nephrotic syndrome.
        J Clin Pharmacol. 2002; 42: 312-318
        • Jun M.
        • Zhu B.
        • Tonelli M.
        • et al.
        Effects of fibrates in kidney disease: a systematic review and meta-analysis.
        J Am Coll Cardiol. 2012; 60: 2061-2071
        • Molitch M.E.
        Management of dyslipidemias in patients with diabetes and chronic kidney disease.
        Clin J Am Soc Nephrol. 2006; 1: 1090-1099
        • Zhao Y.Y.
        • Weir M.A.
        • Manno M.
        • et al.
        New fibrate use and acute renal outcomes in elderly adults: a population-based study.
        Ann Intern Med. 2012; 156: 560-569
        • Vaziri N.D.
        Causes of dysregulation of lipid metabolism in chronic renal failure.
        Semin Dial. 2009; 22: 644-651
        • Saland J.M.
        • Ginsberg H.N.
        Lipoprotein metabolism in chronic renal insufficiency.
        Pediatr Nephrol. 2007; 22: 1095-1112
      3. American Diabetes Association. Standards of medical care in diabetes—2014.
        Diabetes Care. 2014; 37: S14-S80
        • Jellinger P.S.
        • Smith D.A.
        • Mehta A.E.
        • et al.
        American Association of Clinical Endocrinologists' Guidelines for Management of Dyslipidemia and Prevention of Atherosclerosis: executive summary.
        Endocr Pract. 2012; 18: 269-293