Management of dyslipidemia in CKD, dialysis and renal transplant recipient

Dyslipidemia is a well-established metabolic disorder in patients with chronic kidney diseases (CKD), on dialysis and renal transplant recipient. The elevated serum cholesterol levels have a definite role in the development and progression of atherosclerosis and the correlation between elevated serum LDL cholesterol as a risk factor for development of CHD has been firmly established. The HMG-CoA reductase inhibitors (statins) are the current drugs of choice for the treatment of hypercholesterolemia. The treatment with statins effectively lower total and LDL-cholesterol levels, moderately decreases triglycerides (TGs) levels, and have a little effect in increasing HDL-cholesterol levels. The statins therapy reduces the morbidity and mortality associated with CHD in patients with normal renal function. However, the beneficial effect of statin therapy on CVD morbidity and mortality in patients with CKD and advanced ESRD are controversial. Statin therapy reduces CVD mortality in patient with early CKD (not yet requiring dialysis) and their use is recommended for patients with early CKD. However, the recent results from the AURORA and SHARP studies have revealed statins treatment provide no CV mortality benefit in patient with advanced CKD or on long-term dialysis. This may be because athermatous coronary artery disease account for a small proportion of the CVD observed in patients with ESRD and/or on dialysis. In addition, advanced CKD result in structural and functional abnormalities of HDL, impaired cholesterol and chylomicron metabolism which leads to accelerated atherosclerosis and CVD in such patients. Collectively, these abnormalities are largely independent of cholesterol biosynthesis, and consequently are not corrected by statin therapy. Therefore lipid lowering therapy in patient with ESRD should be individualized. Atorvastatin and Rosuvastatin are most potent agents among the available statins in cholesterol lowering but are the most expensive. Simvastatin (20 mg/day) should be considered the drug of choice for most patients with chronic kidney disease because it is less expensive. Pravastatin and fluvastatin are the most suitable agents for transplant patients to achieve target cholesterol levels because of the reduced risk of drug interactions.